County of Santa Clara--2003 Crumbine Award winner.

Editor's Note: The Samuel J. Crumbine Consumer Protection Award for Excellence in Food Protection, named in honor of one of the most renowned public health sanitarians in the United States, 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 program that won the 2003 award--the food safety program of the Santa Clara County, California, Department of Environmental Health. 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 Santa Clara's entire award-winning application is on the FPI Web site at www.fpi.org.

Introduction

In 1997, the Consumer Protection Division (CPD) of the County of Santa Clara Department of Environmental Health began a longterm project to examine and improve our food safety program. Our approach to change looked to our community and our efforts in outreach and education. We looked at strengthening partnerships with allied agencies and organizations. And, we looked inward at previous accomplishments and available resources.

With a food program staff of more than 60, effecting change in a collaborative and inclusive format is a daunting challenge. Our achievements were acknowledged in 2003 with the Crumbine Award for excellence in food protection.

Demographics 

CPD provides educational, consultative, inspection, plan-review, and permitting services in a number of programs, including retail food, public bathing places, drinking water, onsite sewerage, noise control, disaster preparedness, housing, and environmental lead contamination. The single largest program within CPD is food safety, with more than 8,500 facilities under permit.

Situated at the southern tip of San Francisco Bay, Santa Clara Country, until the late-1970s, was dotted with quiet suburban communities and mile after mile of orchards and farmland. Today, we live in a sprawling urban area known the world over as Silicon Valley.

Santa Clara County has 15 incorporated cities and a number of smaller, unincorporated communities. The total county population is 1.7 million, with more than one million residing in San Jose, our largest city.

Housing costs are a major issue, with typical 40-year old tract houses selling for close to a million dollars. Santa Clara County is one of the most culturally diverse areas in the world. Thirty-four percent of our population is foreign-born, and more than 45 percent speak a language other than English at home. Our predominant ethnic groups are Asian (25.6 percent) and Hispanic (24 percent)--significant statistics compared with the national average of 3.6 percent and 12.5 percent, respectively.

With our diversity came a dramatic shift in foods prepared and sold to consumers. In the late 1980s, CPD began to examine foods from both cultural and microbiological perspectives and learned that the key to successful communication between cultures was accepting and understanding each other's perspectives.

Today, a registered environmental health specialist (R.E.H.S.) must learn to deal effectively with cultures and customs "foreign" to "American" customs. Our philosophy: They learn from us while we learn from them. We ask our staff: "Think about your behavior; not just theirs. You are the one entering their establishment. You are the one initiating the inspection. They are going to respond to your behavior." This philosophy does not mean that we overlook critical violations--it simply means that we try to understand why the violations occur before making assumptions and threatening enforcement.

To illustrate our point, we quote a passage from the National Sanitation Foundation in two versions: the only difference is the bold/italic emphasis. With our old attitude:

   ... the level of environmental sanitation
   enjoyed by any group of people living
   together in an organized manner is a
   direct reflection of the knowledge and
   habits of those people. It is a part of their
   culture.... To change the level of sanitation
   of that social group to an effectively
   higher plane, the people must be educated
   as to why a higher level of sanitation
   is desirable and must be motivated
   to want to change their mode of living.
   They must be willing to abandon certain
   aspects of their culture and accept new
   patterns of existence.

With today's philosophy:

   ... the level of environmental sanitation
   enjoyed by any group of people living
   together in air organized manner is a
   direct reflection of the knowledge and
   habits of those people. It is a part of
   their culture.... To change the level of
   sanitation of that social group to an
   effectively higher plane, the people
   must be educated as to why a higher
   level of sanitation is desirable and must
   be motivated to want to change their
   mode of living. They must be willing to
   abandon certain aspects of their culture
   and accept new patterns of existence.

Understanding the issues of diversity has made a major impact on the way we ensure that food safety laws are understood, complied with, and enforced. The burden of learning acceptable behavior regarding food safety is not "theirs" alone; "we" share that burden.

Staffing and Budget

All field and management employees in CPD are either registered environmental health specialists or state-certified trainees preparing for their R.E.H.S. exam. Current staff include a director, four managers/supervisors, 15 senior and senior-lead specialists, 38 field specialists, and five clerical support staff.

Because CPD is fully fee supported, all regulated facilities are required to obtain and pay for an annual permit. In early 2003, examples of load establishment permit fees ranged from a low of $131 for "limited food sales" to a high of $939 for a restaurant with more than 26 employees or a grocery store with more than 20,000 square feet. Fees for food-facility plan checks ranged from $289 for a minor remodel to $1,156 for a new restaurant, bakery, or grocery store. In fiscal year 2003-2004, the total budget for CPD will exceed $7.6 million (see sidebar at right).

Service Delivery

In 1997, the Food Program Coordinating Committee was established to develop a strategy for service delivery improvements; their recommendations led to the following:

* communication improvements,

* mandatory food manager certification,

* quality versus quantity,

* standardization.

* district "sweeps,"

* cross-cultural communication training,

* team inspections,

* joint field specialist and senior plan checker inspections,

* enforcement procedures, and

* cross-training.

Additional recommendations--such as accountability, computer technology, and follow-up inspection fees--were considered in 2001 with the development of the first department-wide strategic plan.

In 1997, a number of new "inspection services" were implemented, enabling field specialists to select an inspection type that best suits the needs of a facility, including

* hazard assessment,

* limited inspection,

* critical hazard factor inspection,

* annual structural review,

* hazard analysis critical control point (HACCP) evaluation, and

* food handler class.

The majority of these services can be substituted for a required "routine" inspection once each year. This flexibility in meeting inspection targets provides field specialists with strategy options for gaining compliance.

Since 1997, our food safety Official Inspection Report (OIR) has evolved to meet changing needs; modifications include

* a Corrective Action Sheet listing health code requirements;

* critical violations highlighted with space for a required correction date;

* use of a single "result code," replacing dual operational and structural status; and

* addition of designated space for recording food temperatures, status of required food safety certification, multiple field activities (e.g., a routine inspection while investigating a complaint), and urban runoff violations.

In March 2001, a significant change to measure the effectiveness of our program was implemented with Performance Based Inspections. Field specialists are now required to conduct at least two "field activities" (e.g., proper techniques for thermometer calibration, cooling, handwashing) during inspections and record results on the OIR. Activities are interactive and selected on the basis of facility needs. The specialist determines whether a response earns a "satisfactory" or "needs improvement," and personalized on-the-spot training is conducted whenever improvement is needed. From our benchmark in May-June 2001, an overall drop of 11 percent in "needs improvement" scores has been recorded.

The "standardization" of field staff working in food safety has long been on the drawing board. Published by CPD in 1995, the Standardized Inspection Guide and Reference was created by an employee committee as a reference and "memory jogger" to ensure consistent, high-quality inspections. In 1997. CPD published the Food Program Standardization Project Classroom Instructors Manual addressing quality of inspections, writing of inspection reports, tools and equipment, field exercises, team inspections, and classroom training modules. And in 1998, we published the Customized CURFFL User's Guide designed to assist in determining the difference between "major" and "minor" deficiencies.

CPD's standardization program was used as a model for California's statewide retail food standardization program. By the year 2000, 100 percent of CPD's registered environmental health specialists and trainees had completed classroom training. By mid-2002, all CPD supervisors and senior-lead specialists had completed field standardization and attained the level of the statewide standard. And, in February 2003, 100 percent of CPD field staff had completed the field standardization process.

In October 2001, three senior-lead positions were added to facilitate compliance in the food safety program. While maintaining a one-third-size district, each of these seniors serves as a consultant when staff are dealing with difficult situations, non-responsive clients, issuing of citations, and preparation for administrative or court hearings.

Enforcement action increased substantially once standardization was initiated and with the support of the new senior positions. In 2002, there was a substantial decrease in the need for enforcement (Table 1).

Outreach and Education

In 1995, our educational campaign had been launched with the publication of a text called Food Safety: It's Everyone's Business. In 1997, we created a new-facility packet containing a copy of the Food Safety text, the state law, required signage, and handouts explaining food safety principles. In addition, nearly 200 presentations are made each year to community and civic groups.

In 1996, CPD initiated a study with San Jose State University to assess our program and revise our inspection process. To measure attitude and knowledge regarding food safety, three hundred surveys (10 percent of restaurants under permit) were mailed to two separate populations--the populations were separated according to whether they had "favorable" or "unfavorable" inspection records. Results concluded that operators who possessed the necessary knowledge and had an appropriate concern for food safety were, in fact, applying food safety principles on a more frequent basis. For years, CPD had offered mini "food handler" classes for facilities requesting such services or because of a facility's failure to comply. The results of the study indicated that the majority of facilities opted to receive their training from national providers, not from CPD. Clearly, work was needed in our educational outreach.

In 1998, an extensive Web site--www. EHinfo.org--was launched as an outreach resource and included online reporting of complaints and service requests. Beginning on July 1, 2001, inspection results for our 8,500 food facilities were made available online; the site recorded more than 70,000 hits in the first six months and 131,000 hits in the next year. The county recently merged all department Web sites, and a significant number of challenges have yet to be resolved.

Foodborne-Illness Investigations

With an average of 450 foodborne-illness investigations conducted by CPD each year, and a number of large-scale outbreaks, a Foodborne Illness Investigation Procedures manual was developed in 2000 as a one-stop shop for conducting an investigation.

We view each investigation as an opportunity to educate both operators and the public. Following an investigation, a response letter is mailed to each complainant, along with the results of our investigation and a copy of an educational food safety pamphlet available in four languages.

Safety and Security

Emergency plans in California have always considered catastrophic events such as earthquake, fire, or flood. In June 2000, less than 50 miles from our office, three California colleagues were murdered while conducting a food safety inspection. In September 2000, spearheaded by CPD, the Bay Area Food Technical Advisory Committee (BAFTAC) designed, developed, and staged a full-day personal-safety curriculum specifically for environmental health specialists, including conflict resolution, verbal-defense training, basic field safety, identification of violent behavior, and development of a personal safety plan. Now sponsored by the California Environmental Health Association, this workshop has been offered statewide and has had more than 1,000 participants.

In response to California's energy crisis and rolling blackouts in the summer of 2000, CPD developed and distributed a flyer titled When Electricity Fails in Food Establishments to all facilities. Following September 11, 2001, CPD responded by developing and distributing Guidelines to Enhance Food Security in Retail Food Establishments.

In 2001, to ensure that staff are prepared to respond, the department pioneered a program called the Department Emergency Response Group, a pre-planned phased-in approach to emergency response that includes multi-discipline response teams. To date, successful tabletop exercises have focused on earthquake, flood, and a biosecurity incident involving self-service food.

Food Safety Training and Certification

California mandated food safety certification in January 2000, requiring the county's more than 6,000 food facilities handling unpackaged food to employ at least one person certified in food safety via a Conference for Food Protection-approved exam.

Even though there was no mandate to provide services, CPD became the first local jurisdiction in California committed to providing a multilingual training and certification program--coordinated, taught, and administered completely in-house. We knew our R.E.H.S. staff could help meet our divergent community needs by providing multilingual classroom training in English, Cantonese, Mandarin, Vietnamese, Spanish, and, with translators, in Farsi.

We selected a textbook never before used in the United States--the easy-to-read Food Safety First Principles. CPD assisted the provider in effectively adapting the text for the American student and then developed an in-house six-hour lesson plan.

We have now trained more than 3300 students. Although approximately 30 percent of students attend our non-English classes, an astounding 65 percent of all students use English as a second language.

The size, scope, and complexity of our program is unparalleled in California--especially for having been implemented without benefit of additional staff or resources, and without outside funding. CPD also volunteers as an exam item writer and has helped to identify ways to improve the exam for non-English speaking students--a critical issue given the diversity of our population.

The coupling of our role as the regulatory expert with our in-house language skills offers a combination that enables students to learn, understand, and implement the complex concepts of food safety. For our efforts, we received statewide recognition for excellence in education as a year 2000 recipient of the California Environmental Health Association's prestigious Stewart Richardson St. Award.

Employee Education

Training for newly hired professional staff--both registered environmental health specialists and trainees--was once largely hit or miss. Our training philosophy today: We make no assumptions. We now provide all newly hired staff with the same base knowledge. In the year 2000, CPD hired one new R.E.H.S. and six trainees; in 2001, we hired one R.E.H.S. and five trainees. Not since 1981 had so many professional staff joined CPD. In accordance with the mandates of California law, CPD focuses considerable resources toward providing as much as 600 hours of on-the-job training for each trainee.

In 2001, we've implemented a training series using both in-house and industry experts to meet the seven hours per year of food safety continuing education required by Food and Drug Administration (FDA) program standards.

Education of Politicians and Decision Makers

Beginning in fiscal year 2003, CPD presented its first "performance-based budget" designed to provide meaningful evaluations of performance linked to resource allocation by emphasizing what is accomplished, rather than what is spent.

These new avenues for tracking and measuring program activities and accomplishments bring a new definition of "education" into CPD's vocabulary by including county politicians and decision makers. Budget documents, quarterly reports, and other requests are now considered "opportunities" to educate--not just a "requirement" to report hack.

Partnerships

CPD believes in "leadership by example" and sets an example by participating in a large number of regional, statewide, and national committees and coalitions.

The Conference for Food Protection

CPD has a long history of supporting and participating in the Conference for Food Protection. At the 2002 conference in Nashville, we had a staff member serving on each of the three councils, with five more staff participating in deliberations from the audience. In addition, our department director serves as a member of the Conference for Food Protection executive board, our senior training and resource specialist serves on two committees, and our senior food program specialist serves on one.

Bay Area Food Technical Advisory Committee

The primary function of the Bay Area Food Technical Advisory Committee (BAFTAC) is to serve as a collaborative resource; it discusses and resolves food safety issues in an advisory capacity for the California Conference of Directors of Environmental Health (CCDEH).

It is the committee's responsibility to conduct any necessary research and submit written reports for statewide distribution by working with federal, state, and local government agencies; non-governmental organizations; industry; academia; and the public. From 1997 to 2002, BAFTAC--whose membership includes 16 local jurisdictions, the California Department of Health Services, industry, ANSI-accredited testing agencies, and academia--was chaired by CPD and was instrumental in developing and authoring a number of major statewide policy guidelines now in effect (see sidebar at right).

In 2002, the BAFTAC chair rotated, but CPD remains an active participant and continues to chair two subcommittees.

Bay Area Food Safety Alliance

CPD's leadership was instrumental in the development of the Bay Area Food Safety Alliance (BAFSA)--a cooperative effort of industry, academia, and regulatory personnel whose purpose is to promote the application of hazard analysis critical control point (HACCP) principles as a collaborative, risk-based method of inspecting retail food facilities.

Local School Partnerships

In 1998, a "handwashing lesson plan" was developed for kindergarten through second grade students and disseminated to the more than 20 private and public school districts throughout the county. In 1999, we worked with San Jose State University in assessing teacher needs and limitations when adding new lesson plans to their already crowded curriculum. That study formed the basis for a region-wide BAFTAC and BAFSA "Food Safety for Kids" initiative to coordinate existing K-6 food safely material and ensure that informed decisions are made when food safety information is being matched with teachers' needs.

Since 2000, CPD has worked with Stanford University as a key participant in a study on Helicobacter pylori, investigating the link between gastroenteritis, stomach ulcers, and stomach cancer. In addition, we continue a long-standing link with San Jose State University as an adviser to graduate students, as a guest speaker, and as an invited participant to the Environmental Health and Safety Engineering Program Advisory Board meetings. We also serve on the Mission College Hospitality Management Advisory Board.

FDA Program Standards

In early 2001, CPD partnered with FDA by enrolling in the Voluntary National Retail Food Regulatory Program Standards. To date, we have achieved full compliance with Standard No. 8 and, based on self-evaluation, are in full or partial compliance in 65 percent of all other areas. Furthermore, areas needing work have been prioritized for completion with short-, medium-, and long-term time frames through fiscal year 2004.

Childhood Lead Poisoning 

The Childhood Lead Poisoning Prevention Program is a CPD partnership with the Public Health Department charged with maintaining awareness of potential sources of environmental lead. The program provides outreach and education to retail food facilities and the public on food-related lead exposure risks, including lead-leaching tableware, ethnic home remedies, Indian homeopathic medicines, Mexican candies and wrappers, and imported caroled goods. The program also provides training and guidance on the identification and field-testing of tableware with hazardous lead content.

Measurable Achievements

Measuring the success of any environmental health program is difficult--how can one effectively measure the absence of illness? Our strategic plan, performance-based budgeting, and service delivery measures provide us with benchmarks and comparative data. Included here are a few noteworthy achievements.

* Our foodborne-illness reporting procedures now ensure that all complaints are immediately reviewed and referred for appropriate action. In 1999, we began to focus on our response time for consumer complaints and have made remarkable improvements (Table 2).

* Each year, we receive approximately the same number of complaints from the public, but since 1997 we have been able to resolve these complaints with a decreasing number of field services (Figure 1).

[FIGURE 1 OMITTED]

* When we initiated standardization, staff conducted an increased number of follow-up inspections, which decreased in subsequent years as inspections became more consistent and the need for follow-up decreased (Figure 2).

[FIGURE 2 OMITTED]

Inspection scores carry little significance since they represent only a snapshot of a facility. Therefore, effective in 2000, we no longer use numeric scoring for assessment or evaluation. Comparison data are now available only for the "operational status" of excellent, good, average, fair, or poor. In 2001-2002, we had a substantial increase in the overall number of inspections rated "good" or "average" compared with our benchmark year of 1997.

The Future

The past six years have been a true success story for CPD--our service delivery improvements, education and outreach, and professional partnerships have achieved significant and measurable steps forward.

Balancing the needs of our division, our employees, and the public we serve is an ever-present and ever-changing challenge. Using the strategic plan as a roadmap--and fine-tuning our performance-based budget--we will remain poised to effectively face future challenges with creativity and innovation to enhance the lives of residents and visitors in Santa Clara County.

Average Annual Workload in CPD's Food Safety Program

* 8,500 retail food facilities under permit **

* 1,700 permits issued for temporary food booths

* 500 facilities undergoing plan review and construction

* 450 alleged foodborne-illness outbreaks investigated

* 200 enforcement actions taken

* 40 food safety certification classes

* 200 community food safety presentations

* 1,200 assistance requests and complaints investigated

** Number of retail food facilities under permit includes 5,150 on-site eating and drinking establishments, 2,300 off-sale food establishments (e.g., markets), and 1,050 food vehicles.

California Guidelines/Documents Developed by BAFTAC Under CPD Leadership

* Guidelines for Retail Fish Sales from Commercial Fishing Vessels (May 1999).

* Guidelines for the Installation and Use of Open-Air Barbecue Facilities (revised May 1999).

* Environmental Health Requirements for Certified Farmers' Markets (September 1997, revised June 1999).

* Buffet Service Guidelines (revised June 1999).

* Guidelines for the Installation and Use of Tandoor Ovens (July 1999).

* Bed and Breakfast/Agricultural Homestay Food Establishment Guidelines (revised June 2000).

* Procedures for Development of Food Safety Notices (June 2000).

* Report on Fish and Lobster Sales from Semi-Trailers at Retail Markets (July 2000).

* Mechanical Exhaust Ventilation Exemption Letters (July 2000).

* Compendium of Information--contains new, revised and updated guidelines (July 2000).

* Temporary Events Guideline--for providing enforcement coordination between jurisdictions (ongoing since 2001).

* A procedure for annual updating of Compendium of Information (completed, 2002)

* Training safeguards specific to the R.E.H.S. profession to improve personal safety during inspections, enforcement, and office activities (February 2003).

Documents can be viewed on the CCDEH Web site at www.ccdeh.com.

TABLE 1

Trends in CPD
Enforcement Action

Year   Enforcement Action

1997           96
1998          164
1999          145
2000          460
2001          610
2002          173

TABLE 2

CPD's Decreasing Complaint Response Times

              Complaint Type--Average
              Response Period in Days

Year   Epidemiological   Non-Epidemiological

1999        16.15               18.96
2000        20.11               22.52
2001        12.30               22.46
2002        10.00               10.20

Acknowledgements: Special thanks go to all Consumer Protection Division employees who participated in the development of the nomination document, most notably:

* Richard Fuchs, M.P.H., R.E.H.S., director of CPD;

* Rochelle Gaddi, R.E.H.S., senior environmental health specialist; and

* Jeff Gans, R.E.H.S., senior food program specialist.

Corresponding Author: Vicki Everly, Senior Training and Resource Specialist, County of Santa Clara, Department of Environmental Health, Consumer Protection Division, 1555 Berger Drive, Suite 300, San Jose, CA 95112-2716. Email: [e-mail].