The vital role of restaurant health inspections.

Editor's note:

Through NEHA's long-standing and excellent relationship with NSF International, NEHA was granted permission by NSF International to share with the Journal's readership various papers that were presented November 16-18, 1998, at the "First NSF International Conference on Food Safety" in Albuquerque, New Mexico. This paper, "The Vital Role of Restaurant Health Inspections," is one of them.

It is important to note that these papers were screened by' an NSF International/Conference for Food Protection advisory committee prior to their presentation at the conference, but they have not been peer reviewed by NEHA's Journal program for technical accuracy.

Because these papers contain useful and interesting ideas and information that may be either delayed or lost if sent through the Journal's normal peer review process, NEHA has decided to publish them as presented, with only minor editorial modifications.

We hope you look forward to more of these papers in future issues of the Journal!

Introduction

The primary goal of a food inspection program is to protect the public from foodborne disease. This goal is best achieved with regular inspections of food-handling establishments, during which poor food hygiene practices and substandard environmental conditions are identified and corrected. In 1989, there were over one million retail food establishments in the United States (1). On the basis of the observed rate of growth, the number of retail food establishments is now believed to be at least 1.5 million (2). The phenomenal rate of growth in the retail food industry has given rise to two major public health concerns:

1. More and more people are consuming retail foods; thus, if appropriate controls are lacking, the potential for the spread of foodborne disease is greater.

2. Shrinking public health budgets have forced many agencies to decrease food inspection activities and, in some cases, to hire persons who lack the technical skills to perform effective food safety inspections.

The average frequency with which restaurants are inspected in the United States is twice a year; research has shown that more frequent inspections may be needed to maintain high levels of hygiene and reduce the spread of foodborne diseases (3-5). On the other hand, many people have questioned the importance of restaurant health inspections as a food safety strategy. In fact, some have called for the abolishment of inspections on the grounds that they produce no major benefits. Therefore, to test the hypothesis that inspections are still a valid food safety strategy, the authors designed a study to determine how the sanitary rating and the incidence of critical violations change in response to changes in inspection frequency The conceptual basis for this research is that if health inspections are a valid food safety strategy in restaurants, there will be a positive dose-response relationship between frequency of inspection and sanitary rating.

TABLE 1

Critical Food Code Violations

Violation              Operational Definition

Food temperature       Food held at an inappropriate temperature for
                       storage, preparation, display, or service.

Handwashing            Handwashing facilities inadequate and/or
                       inaccessible.

Food protection        Food stored, prepared, displayed, or served
                       in a manner that did not adequately protect
                       it from contamination.

Sanitization           Temperature,concentration, or cleanliness of
                       sanitizing rinse solutions did not meet the
                       standards of the food code.

The study was carried out in Bloomington, the third largest city in the state of Minnesota. Bloomington has a population of 86,000 and is located 15 miles south of Minneapolis in one of the fastest-growing metropolitan areas in the United States. At the time the data for this study were collected, there were approximately 320 restaurants in Bloomington. These restaurants were divided into two classes based on the complexity of their menus and the level of risk associated with their operations (6). "Class A" restaurants were large, full-service establishments, and "Class C" restaurants comprised smaller restaurants, snack counters, and delicatessens.

From the mid 1960s until 1988, each restaurant in Bloomington was inspected four times per year. In 1988, because of a lack of resources, the number of inspections was reduced to three per year. This change in inspection frequency prompted the decision to examine data from 1987 and 1988 in an attempt to evaluate the impact of restaurant health inspections. All routine restaurant health inspections in Bloomington are based on the demerit scoring system developed by the U.S. Public Health Service (7). In this system, each code violation has a weight of between one and five demerit points. The total number of demerit points is subtracted from 100 to give an overall sanitary rating (score).

Methods

The 1987 and 1988 inspection reports generated by City of Bloomington inspectors were reviewed. From this database, Class A and Class C restaurants were selected and grouped according to the following criteria:

* establishments inspected four times in 1987 and three times in 1988 formed Group 1,

* establishments inspected three times in 1987 and two times in 1988 formed Group 2, and

* establishments inspected four times in 1987 and two times in 1988 formed Group 3.

Of a total of 83 restaurants selected, 20 were in Group 1, 37 were in Group 2, and 26 were in Group 3. There were 60 Class A and 23 Class C restaurants among the selected establishments [ILLUSTRATION FOR FIGURE 1 OMITTED].

Mean 1987 scores were compared with mean 1988 scores for each group of restaurants selected. Also, for each group of restaurants, the average number of times four critical violations were observed in 1987 inspections was compared with the average number of times the same violations were observed in 1988. The four types of violations and their operational definitions are given in Table 1. These violations were selected for the comparison because they are very critical in food safety and are routinely identified by registered sanitarians. (All the data used in this study were collected by registered sanitarians.)

Data analysis was performed with Epi Info[R] software (Centers for Disease Control and Prevention, Atlanta). Paired t-tests were performed to detect significant changes in mean inspection scores and mean number of critical violations for each group of restaurants.

Results

Figure 2 shows the changes in mean scores from 1987 to 1988 for restaurants inspected four times in 1987 and three times in 1988. Mean 1987 scores among this group of establishments were significantly higher than mean 1988 scores (p [less than] .05, paired t-test). The restaurants in this category scored an average of 2.5 percentage points less in 1988 than in 1987 (standard deviation 4.3). The median and modal changes in mean score were -4 and -9 percentage points, respectively The changes in mean scores for Class A and Class C restaurants did not differ significantly in this group (p [greater than] .05, Kruskal-Wallis nonparametric test). Only three (15 percent) of the establishments in this group had mean scores that were higher in 1988 than in 1987. Sixteen (80 percent) had a lower mean score in 1988. The mean score remained the same for one restaurant (five percent).

Figure 3 shows the changes in mean scores from 1987 to 1988 for restaurants inspected three times in 1987 and two times in 1988. The mean scores for this group of establishments did not change significantly between 1987 and 1988 (p [greater than] .05, paired t-test). The restaurants in this group scored an average of one percentage point less in 1988 than in 1987 (standard deviation 4.4). The median and modal change in mean scores were zero and three percentage points, respectively. Changes in mean scores for Class A and Class C did not differ significantly (p [greater than] .05, Kruskal-Wallis nonparametric test). Figure 3 also shows that 13 (35.1 percent) of the establishments in this group had mean scores that were higher in 1988 than in 1987. For 19 establishments (51.4 percent), mean scores were lower in 1988. Mean scores showed no change for five establishments (13.5 percent).

Figure 4 shows the changes in mean scores from 1987 to 1988 for restaurants inspected four times in 1987 and two times in 1988. Among these restaurants, mean 1987 scores were significantly higher than mean 1988 scores (p [less than] .05, paired t-test). Overall, these restaurants scored an average 3.2 percentage points less in 1987 than in 1988 (standard deviation 5.2), and the median and modal changes in mean scores were -3.0 and -4.0 percentage points, respectively. The average change in mean scores was not significantly different for Class A and Class C restaurants (p [greater than] .05; Kruskal-Wallis nonparametric test). Five (19.2 percent) of the establishments in this group had mean scores that were higher in 1988 than in 1987. Nineteen (73.1 percent) had lower mean scores in 1988. Mean scores showed no change for two (7.7 percent) of the establishments.

Figure 5 compares the number of times four specific types of food code violations were observed in 1987 and the number of times they were observed in 1988. The actual number of violations was increased by 10 to aid in graphing. Only food temperature violations increased significantly over the two years; however, there were also slight increases in the numbers of handwashing violations and food surface sanitization violations. Food temperature violations increased from two per inspection in 1987 to approximately four per inspection in 1988. This increase was statistically significant (p [less than] .05, Kruskal-Wallis nonparametric test).

Discussion

The results of this study indicate that the sanitary rating of a restaurant is positively associated with the frequency with which the restaurant is inspected. The finding supports the authors' basic assumption that restaurant health inspections continue to play a vital role in protecting the public against foodborne disease. Since the introduction of governmental systems of food quality control, officials have recognized that along with appropriate regulations governing the retail food trade, regular inspection of food establishments is needed for education and enforcement purposes (8). Early restaurant inspections were autocratic; they relied more heavily on enforcement actions than on education to achieve food safety. Today, with the advances in our understanding of the factors that influence behavior change, it is accepted that education of food workers plays a far more significant role in promoting safe behavior than does enforcement. In many areas of the United States, workers are not required to undergo food safety training before being employed in restaurants. This circumstance, combined with the high staff turnover typical in restaurants, creates a need for public health agencies to provide ongoing education for workers. Frequent and regular inspection of restaurants by qualified environmental health specialists or sanitarians is the most reliable means of disseminating up-to-date food safety information to food workers on an ongoing basis. Consequently, the observed decrement in the sanitary rating of restaurants may be the manifestation of the reduction in opportunities that health inspectors have to educate new food workers during inspections.

Recently, innovative approaches such as the hazard analysis and critical control point (HACCP) method have been proposed for improving food safety in restaurants. For the most part, these strategies have emphasized the need for greater responsibility on the part of the food industry in ensuring the safety of the end product. This is a move in the right direction; however, the question of the practicality of implementing HACCP in restaurants has yet to be fully answered (9). In fact, if one considers the pace and scale of operations, as well as the chronic noncompliance with basic food protection regulations that occur in most restaurants, it is almost impossible to imagine that food workers will devote themselves to the task of properly implementing HACCP On the contrary, increasing demand by patrons for faster service fosters the tendency of food workers to cut corners on safety in favor of more rapid food production. This tendency particularly relates to issues like proper handwashing, according to the U.S. Food and Drug Administration (FDA) Food Code. It is therefore not surprising that over 50 years after publication of the Ordinance and Code Regulating Eating and Drinking Establishments, noncompliance with handwashing guidelines is still widespread in restaurants (10).

The finding of a significant increase in food temperature violations for all groups of establishments from 1987 to 1988 is further evidence of the vital role health inspections play in preventing foodborne diseases. This conclusion is amply supported by several other studies (11-13). It should be noted, however, that health inspections alone cannot always prevent foodborne disease outbreaks. Evidence is strong that a poor sanitary rating is a good indicator of the likelihood that an establishment will be involved in a foodborne disease outbreak (14). Still, prevention of such an outbreak requires a comprehensive approach to food safety, with effective management controls and a commitment on the part of each food worker to following proper procedures while preparing food (15).

(Adapted with permission from Proceedings of the First NSF International Conference on Food Safety, Albuquerque, New Mexico, November 16-18, 1998.)

Corresponding Author: Paul B. Allwood, M.P.H., R.E.H.S., City of Bloomington Environmental Health Division, 2215 W. Old Shakopee Road, Bloomington MN 55432.

REFERENCES

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2. Edberg, C.W., K.L. MacDonald, and M.T. Osterholm (1994), "Changing Epidemiology of Foodborne Disease: A Minnesota Perspective," Clinical Infectious Diseases, 18:671-682.

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4. Riben, P.D., E. Campbell, R.G. Mathias, and M. Wiens (1994), "The Evaluation of the Effectiveness of Routine Restaurant Inspections and Education of Food Handlers: Critical Appraisal of the Literature," Canadian Journal of Public Health, 85(51):56-60.

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6. Bloomington City Code (1996), Bloomington Minnesota: City of Bloomington.

7. U.S. Public Health Service (1976), Food Service Sanitation Manual, Washington D.C.: Government Printing Office.

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10. U.S. Food and Drug Administration (1997), Food Code, Washington, D.C.: Government Printing Office.

11. Corber, S., P. Barton, C. Dulberg, and R.C. Nair (1984), "Evaluation of the Effect of Frequency of Inspection on the Sanitary Conditions of Eating Establishments," Canadian Journal of Public Health, 75:434-438.

12. Riben, P.D., W. Cocksedge, A. Hazelwood. B. Kirshner, R.G. Mathias, J. Pelton, and M. Wiens (1994), "Routine Restaurant Inspections and Education of Food Handlers: Recommendations based on Critical Appraisal of the Literature and Survey of Canadian Jurisdictions on Restaurant Inspections and Education of Food Handlers," Canadian Journal of Public Health, 85(51):67-70.

13. Mathias, R.G., W. Cocksedge, A. Hazelwood, and R. Sizto (1995), "The Effect of Inspection Frequency and Food Handler Education on Restaurant Inspection Violation," Canadian Journal of Public Health, 86:46-50.

14. Irwin, K.I., J. Ballard., J. Grendon, and J. Kobayashi (1989), "Results of Routine Restaurant Inspections Can Predict Outbreaks of Foodborne Illness: The Seattle-King County Experience," American Journal of Public Health, 79(5):586-590.

15. Penman, A.D., M.M. Currier, R.M. Webb, and C.H. Woernle (1996), "Failure of Routine Restaurant Inspections: Restaurant-Related Foodborne Outbreaks in Alabama 1992, and Mississippi, 1993," Journal of Environmental Health, 58(8):23-25. s all had bee