Preparing to receive the Crumbine Award.

Introduction

Multnomah County (population 650,000) is located at the confluence of the Willamette and Columbia Rivers, which flow into the Pacific Ocean. Portland, Oregon, is the largest city of five in our jurisdiction. The force generated by the confluence of rivers is an inspiration for our model of continuous improvement in food safety. The model relies on two primary tools: 1) the Food and Drug Administration (FDA) Voluntary National Retail Food Regulatory Program Standards, (FDA, 2001a), which we use to evaluate and develop content expertise; and 2) the concept of the 10 Essential Services of Environmental Health, which we use to evaluate and develop a sustainable girder within the larger context of environmental health services. Use of this dual method prepared Multnomah County Health Department (MCHD), Oregon's largest local public health agency, to be the winner of the 2006 Crumbine Award.

In 1999, MCDH's Environmental Health Services (MCEH) conducted a visioning process to help identify strategic goals, objectives, and outcomes that would expand the depth and breadth of our focus in food safety. The purpose was to reduce the occurrence of the risk factors that the Centers for Disease Control and Prevention (CDC) had identified as contributing to foodborne-illness outbreaks and to improve understanding of the connection between health and the environment. The goal is to improve health outcomes by implementing effective interventions. This strategic-planning process led to systematic improvements in the MCEH foodborne-illness program. The Crumbine Award jury found the Multnomah County Food Safety Program to be impressive in the following categories: 1) community outreach, 2) education and training efforts, 3) foodborne-illness database, 4) gap analysis, 5) measurable and quantifiable data, 6) use of grants to supplement funding, and 7) well-defined strategy and outcomes. A description of the priority elements of the FDA Food Program Standards and the 10 Essential Services of Environmental Health as capacity-building tools follows.

[ILLUSTRATION OMITTED]

Essential Services of Environmental Health

A preliminary analysis of the environmental health system was conducted to determine current capacity and to find critical gaps using the 10 Essential Services of Environmental Health framework developed by Carl Osaki, R.S., M.S.P.H., of the University of Washington, as part of a CDC-funded strategy to build environmental health capacity at the local level (Osaki, 2004). Priority gaps for which we sought resources were education and outreach, surveillance, research, and workforce development.

An important first step was taken to address capacity gaps. A person with grant-writing and evaluation expertise was hired to assist in locating new revenue and resources. Identification of gaps and a proactive search for additional funding resulted in acquisition of the following resources: 1) a three-year $300,000 Essential Services Capacity Building grant from CDC; 2) a public health prevention specialist position funded for two years by CDC; 3) a three-year $980,000 Healthy Home grant from the Department of Housing and Urban development (HUD); 4) a one-year $30,000 Asthma Trigger Reduction grant from the U.S. Environmental Protection Agency (U.S. Agency); 5) a one-year data-tracking grant from the Environmental Public Health Tracking (EPHT) Program; 6) a one-year $30,000 food safety education grant from the National Association of County and City Health Officials (NACCHO); and 7) a one-year $20,000 U.S. EPA lead grant for outreach to the African refugee population.

Workforce Development

In an effort to stave off the effects of a retiring workforce and a limited academic curriculum in environmental health, MCEH developed strategies for hiring competent and qualified environmental health personnel. The development of an incoming environmental health specialist workforce constitutes a critical step in the implementation of quality food safety and protection services by ensuring an incoming stream of qualified people. The three-year CDC capacity-building grant received in 2004 has enabled the department to improve workforce development through educational partnerships with local academic institutions that provide environmental health internship opportunities (CDC, 2006). The internships train and educate students to pique their interest and better prepare them for the environmental health workforce. Collaborative activities include developing the internship curriculum, matching students to internship opportunities, and evaluating student performance. Of the 10 interns who have participated in the program, two have been hired as permanent employees.

The grant also supports partnering with academic institutions to develop research opportunities. MCEH partnered with Portland State University to conduct community-based participatory research in an effort to identify and prioritize environmental concerns from a community perspective. This led to strong grant partnerships and better knowledge in the community about environmental public health efforts.

Education and Outreach

Education is the best means of providing food service workers with critical knowledge and skills that enable them to store and prepare food safely, thus minimizing the risk of foodborne illness. Industry surveys indicate that food service workers consistently lack knowledge about safe food-handling techniques. In addition, Multnomah County has a high number of workers for whom English is a second language, in part because increased numbers of refugees and immigrants are working in the food industry. During the period from December 2001 through April 2002, for example, 8,115 people speaking at least 13 different languages applied for a food handler certificate. Of these, 30 percent had less than a high school education. About 10 percent had less than sixth-grade education. The overall failure rate for first-time English-speaking test takers was 16 percent. By comparison, the rate was 48 percent for Chinese speakers and 68 percent for Spanish speakers, with varying results in other languages. Because of the diversity of languages and cultures in the county, it was clear that improvements were needed in the capacity to offer culturally competent and linguistically appropriate methods of educating the public about food safety.

The National Restaurant Association estimates that turnover is 400 percent per year among retail workers and 100 percent among food service managers, levels that make it difficult to maintain an adequately trained food-handling workforce. Every year, food handler training and testing opportunities are provided for approximately 15,000 people at over 50 locations throughout Multnomah County, including community college campuses, public schools, food banks, health centers, grocery stores, social service organizations, and community centers. Over the past five years, five different methods of training and testing food industry workers have been developed in the following languages: English, Spanish, Chinese, Russian, Vietnamese, and Korean. The methods include 1) books for print learners, 2) written tests, 3) oral tests for audio learners, 4) a food safety video tailored to the Food Code and designed for individuals who do not read well or who have poor English skills, and 5) an online food handler education-and-testing Web site. The development of the video and the development of the online testing were partially supported by grants.

Our food handler test data showed that English-as-a-second-language speakers had a high failure rate on the first and second tries. A grant from the National Association of County and City Health Officials (NACCHO) allowed us to develop and translate our food safety video into Russian, Spanish, Vietnamese, Tagalog, and Chinese (Cantonese and Mandarin). Currently, revisions are under way to incorporate new food handler learning objectives. Evaluation of our video in 2004 showed an increase in the first-time pass rate of Spanish speakers from 68 percent to 93 percent. In 2005, the video materials and oral-testing materials were transformed to create an online food handler Web site that is culturally and linguistically competent in seven languages, that supports both "print" learners and "oral" learners, and that reaches less literate populations by using pictures and audio streams. Once a user passes the test, he or she can print out a food handler card that is valid statewide. Since its inception in June 2005, the Web site has received 148,455 hits from individuals interested in increasing their food safety knowledge and skills. The test has been taken 18,330 times (that number includes nonpaying test takers for whom no card was issued, individuals who did not complete the test, and those who failed the test). From July 2005 through July 2006, 14,638 online food handler cards were issued. By partnering with public libraries and unemployment offices, we are working to improve access for non-English speakers and individuals who do not own a computer.

FDA Voluntary National Retail Food Program Standards

For a department facing ever-increasing demands for environmental health services in an era of government budget tightening, the program standards became a tool for identifying the future direction of services and an impetus for creatively seeking out alternative environmental health resources. The FDA food program standards became the foundation supporting strategic planning, helping to identify assets and challenges to the food safety program, serving as a marketing tool for increases in resources, and establishing program performance indicators based on occurrence of foodborne-illness risk factors that allow comparisons to be made nationally (FDA, 2001a). FDA's food program standards assessment highlighted the same gaps as the 10-essential-services analysis, with the added feature that it homed in on food safety functions with precise tools.

Foodborne Illness

Priority was given to meeting the foodborne-illness standard. The foodborne-illness standard focuses on development of a system that ensures active surveillance, timely and appropriate response, coordination of services, implementation of epidemiological best practices, and ongoing trend analysis. Two of the major strategies for meeting this standard are described below.

FBI Database

In 2003, the department received a $5,000 grant from FDA to develop and implement an innovative foodborne-illness (FBI) database that allows us to identify foodborne-illness antecedents and causative factors leading to outbreaks. The database greatly increases our capacity to analyze foodborne-illness trends over time, to reduce the occurrence of the CDC risk factors identified as contributing to foodborne-illness outbreaks, and to protect the health and safety of our community. We analyze the data by running queries and cross-referencing information stored in the FBI database with information from a secondary, linked inspection database to reveal pertinent information that may correlate to a foodborne-illness outbreak. Each risk category is assigned an FBI risk point value. The computer then calculates a score that assesses the likelihood that a foodborne-illness outbreak is occurring. Any foodborne-illness complaint that scores six or higher is referred to the Multnomah County Health Department Communicable Disease unit, and an action plan is developed for the investigation. Simultaneously, MCEH may conduct a facility investigation to determine the possible source of the outbreak. A complaint that scores five or lower will be maintained in the database and monitored for further information that could elevate the score to FBI outbreak level. The FBI database is located on a secured server, which is shared with the Communicable Disease Unit so that the epidemiologist and communicable-disease staff can access it at any time. Since February 2003, 96 percent of all foodborne-illness outbreaks have been confirmed as outbreaks, indicating that the database is correctly identifying and applying FBI criteria.

FBI Manual

To accompany the FBI database, MCEH developed a foodborne-illness investigation manual that details how the FBI database is used and how Multnomah County Health Department and MCEH will investigate and respond to foodborne-illness complaints within their jurisdiction. These procedures were developed by a cross-departmental team within the health department to make follow-up on foodborne-illness complaints more efficient and more effective at preventing further disease transmission. MCEH also developed a communication flow chart that clearly identifies the roles of the multiple agencies and disciplines that are responsible for investigating foodborne-illness outbreaks.

Our new FBI database uses a technology that greatly reduces the amount of time it takes to analyze collected data so that intervention (consisting of investigation and response) occurs sooner and the health impact is minimized. In the old paper-driven system, it was easy to miss outbreak indicators. The new system allows us to identify trends and risk factors to further improve the food safety program.

The FBI database model was presented at the FDA Pacific Regional Retail Food Seminar in 2004. Singapore and Guam requested copies. The model was also presented at an FDA food-program-standards-audit training session in July 2004, and MCEH provided copies of the database. Katey Kennedy and John Marcello, members of the FDA National Retail Food Team, have shared this model with food programs across the country. The International Association for Food Protection is revising its current FBI investigation manual to replicate the MCEH format.

Risk-Based Inspections

A baseline study of our restaurant inventory of 3,000 facilities revealed the need to evaluate and potentially revise our current model, which emphasizes seating capacity as licensing/inspection criterion. A new approach emphasizing risk as the licensing and inspection criterion is being considered. In 2002, the statewide adoption of the 1999 Food Code improved our ability to promote food safety by focusing on five risk factors identified by CDC as contributors to foodborne illness: 1) unsafe sources, 2) inadequate cooking, 3) improper holding, 4) contaminated equipment, and 5) poor personal hygiene. The Food Code also established five key public health interventions for protection of consumers' health: 1) demonstration of knowledge, 2) employee health controls, 3) controlling hands as a vehicle of contamination, 4) time and temperature parameters for controlling pathogens, and 5) consumer advisory (FDA, 2001b). Currently, all restaurants are licensed on the basis of seating capacity; the larger the seating capacity is, the greater the licensing fee. This model does not take into consideration risk factors or allow for allocation of increased resources to correct risk factors in the long term. A small facility such as a catering operation, which has zero seating capacity, may, for example, have a much higher potential to spread foodborne illness because it serves a large population and has a complex menu that requires heating, cooling, and transporting food. Conversely, a coffee shop with many seats but a limited menu may have lower risk than the seating capacity implies. In the CDC-funded risk-based pilot project, the food preparation methods used by the facility determine whether the restaurant is defined as an operation involving low, medium, or high complexity. Low-complexity restaurants that do not serve foods with critical control points should have fewer risk factors than high-complexity establishments.

Data obtained from the pilot project were used to determine which is a better indicator of facility food safety practices: the number of critical violations per seating capacity or the number of critical violations per complexity category (low, medium, or high). The first step of the study was to categorize restaurants by the complexity of their menus. A team of environmental health professionals (including MCEH environmental health specialists, an FDA food specialist, the State of Oregon EHS-Net coordinator, and Oregon Restaurant Association members) was convened to develop risk definitions (Table 1).

After categorizing restaurants and conducting a one-year time study, MCEH studied the data using logistic regression analysis, a statistical method, to control for certain variables and isolate the impact of variables like risk while controlling for variables like seating; this analysis identified the strength of a relationship. The total number of restaurants analyzed was 2,658, and the total number of inspections was 4,477. Logistic regression analysis was used to determine whether risk or seating was a better predictor of critical violations. (Table 2).

Findings

When risk and seating are taken into account together, they are a stronger predictor of critical violations than risk or seating capacity alone. As a result, the team recommended creation of a licensing/inspection fee structure in Oregon that takes both seating capacity and risk into account.

Standardization of Inspections

Standardization of inspections is a priority initiative because this effort will allow us to focus on critical issues and support industry expectations of consistency and equity. Registered environmental health specialists perform approximately 8,000 inspections and respond to approximately 373 foodborne- or waterborne-illness complaints a year, and they consistently meet state requirements. The standardization model is based on continuous quality improvement and is overseen by a Standardization Team. This workgroup reviews violation data for consistency and reviews foodborne-illness outbreaks to focus future inspections on findings and trend results. Other factors that are reviewed include assurance that unresolved critical violations will be resolved, assurance that complaint response will be timely, and provision of a trained and certified staff modeled after the FDA Program Standard #2 (Trained Regulatory Staff). Five environmental health specialists have completed FDA standardization training and have met standardization criteria. These environmental health specialists then support standardization of other staff.

Enforcement

In 2002, an enforcement model incorporating a Civil Penalty Ordinance was developed to strengthen enforcement capacity. The ordinance provides for equitable collection of all available licensing fees to maximize our service capacity. It also ensures a fair and equitable service system for our customers and a process by which they can appeal if they disagree with the issuance of a penalty. Most important, it allows the agency to minimize additional risks to the community by responding to imminent public health issues or events effectively.

Steps to Success in Other Jurisdictions

The actions and strategies implemented to win the Crumbine Award were twofold and spanned five years. Strategy One involved assessing the strengths and weaknesses of the environmental health infrastructure capacity, applying the concept of the Essential Services of Environmental Health developed by the University of Washington. This strategy was designed to drive a sea change in the health department to produce four outcomes: 1) broaden the understanding of environmental and public health staff about the critical components necessary for environmental health to be effective within a public health model, 2) enhance relationships with the food industry on the basis of industry and public health values, 3) recognize the need for capacity-building resources through grant writing and general-fund support, and 4) maintain and develop the technical capacity of core food safety services. Strategy Two was a parallel strategy: adoption of the FDA Voluntary National Retail Food Program Standards as a tool for driving the enhancement and standardization of the food program within the environmental health framework. The FDA food program standards provide a mechanism for evaluating the food program against national benchmarks, setting a bar for food safety expertise, and developing methods for achieving that expertise.

Although Multnomah County has not completely met the FDA food program standards nor succeeded in developing full capacity in the Essential Services of Environmental Health, the aim is to strive for excellence by using these two tools to set our sights and to measure our accomplishments. These methods can be applied to any jurisdiction in the country. Combined with belief in the value of protecting the public and creating healthier communities, being tenacious (some call it stubborn) will lead to success.

Corresponding Author: Lynn George, Program Development Specialist Senior, Multnomah County Health Department, 3653 SE 34th Ave., Portland, OR 97202. E-mail: [e-mail].

REFERENCES

Centers for Disease Control and Prevention. (2006). Environmental health services branch cooperative agreement, capacity building 2004-2007: Information on environmental health programs. Retrieved October 31, 2006 from http://www.cdc.gov/nceh/ehs/CapacityBuilding/default.htm.

Food and Drug Administration. (2001a, June 28). FDA's recommended national retail food regulatory program standards [Draft]. Retrieved November 3, 2006, from http://www.foodprotect.org/doc/ProgramStandards2005v2.doc.

Food and Drug Administration. (2001b). Food Code. Retrieved November 3, 2006, from http://www.cfsan.fda.gov/~dms/foodcode.html.

Osaki, C. (2004). Essential services of environmental health [CD-ROM]. Northwest Center for Public Health Practice. Retrieved October 31, 2006, from http://www.nwcphp.org/training/coursesexercises/courses/essential-services-of-environmental-health.

Lila Wickham, R.N., M.S.

Ken Yee, R.E.H.S.

Lynn George

TABLE 1 Complexity Definitions According to the Risk-Rating Pilot
Project

Restaurant Risk    Definition Based on Menu Complexity

Low complexity     Prepackaged foods (excluding raw animal foods), non-
                   potentially hazardous beverages and bakery items,
                   dairy product that is not dispensed through a soft-
                   serve dispensing machine, product delivered in bulk
                   quantity by a licensed food service operation or off-
                   premise commercial processor and is maintained and
                   served at the same temperature as it was when
                   delivered. Note: espresso beverages are okay.
Medium complexity  For hot foods: prep/serve or cook/serve and hot-
                   holding for same-day service and no cooling of
                   potentially hazardous food.
                   For cool foods: prep/serve and cold-holding of
                   potentially hazardous food.
High complexity    Cooling of potentially hazardous foods; raw/
                   undercooked food or potentially hazardous meats
                   offered as a menu item; poultry products; serving of
                   eggs, fish, shellfish, or foods that have these
                   potentially hazardous items as raw ingredients;
                   transport of potentially hazardous food (as in a
                   catering food service); food processing that involves
                   smoking and curing; any operation that involves
                   reduced-oxygen packaging for extended shelf life.

TABLE 2 Restaurants by Risk Category, 2005: Full-Service Restaurants in
Multnomah County Receiving Semi-annual Inspections

Risk Category  Percentage  Number

Low              7.1 %       189
Medium          28.1 %       747
High            64.6 %     1,722
Total          100 %       2,658