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Improving Food Safety Knowledge for All
Summary
Impact Statement:
After noting that the scores on certification exams given after food safety training courses to restaurant workers were markedly lower for workers in Chinese restaurants, the county undertook a QI project that included Chinese restaurant owners, managers and workers in the process. Multiple changes were made in the training process to adapt it to the needs of the workers, including training and testing in simplified Chinese and offering the course at times when the workers could attend.
Summary:
The Grand Traverse County Health Department (GTCHD) Quality Improvement (QI) team selected food safety training disparities among Chinese restaurant workers as an improvement project. Food safety training exam scores were disproportionately low among Chinese food service workers in Grand Traverse County. The goal of the project was to use QI techniques and tools to determine why such a learning disparity existed among Chinese food service workers and to develop an improvement theory to address the problem. The strategy involved assessing the needs of Chinese food service workers. A key component of the strategy involved including Chinese restaurant owners/managers/workers in the process to accurately identify the needs of the workers regarding food safety training. Once the needs assessment was done and potential root causes were identified, an improvement theory was developed to improve food safety knowledge.
Organization that conducted the QI initiative:
Grand Traverse County Health Department
Citation:
Thorell, D. Public Health Quality Improvement Exchange. Improving Food Safety Knowledge for All. Fri, 11/16/2018 - 11:00. Available at http://www.phqix.org/content/improving-food-safety-knowledge-all. Accessed October 10, 2024.
Background and Aim
Aim statement:
Original Aim: By January 15, 2011, food service workers from Chinese restaurants will demonstrate a 20% increase in the ServSafe exam passing
rate after receiving culturally appropriate training and educational materials provided by GTCHD Environmental Health program staff.
Revised Aim: By January 15, 2011, food service workers from Chinese restaurants will demonstrate a 20% increase in the ServSafe exam passing rate.
Revised AIM Statement: By January 15, 2011, food service workers from Chinese restaurants will demonstrate a 20% increase in the ServSafe exam passing rate.
Need For The QI Initiative:
The Michigan Department of Agriculture (MDA) mandated that by June 30, 2009, at least one person in authority at a licensed food service establishment be certified by a nationally accredited food safety organization. GTCHD offered certification through the National Restaurant Association’s (NRA's) ServSafe® program. Most restaurants became certified through ServSafe with a 94% passing rate. However, only 5 of the 12 workers from Chinese restaurants who attended NRA ServSafe courses in 2009 actually passed to become certified. This failure rate of 58% is well above the failure rate of 4% observed in the cohort of remaining students. The failure rate among Chinese food service workers underscores a problem that has always existed within the GTCHD Food Service Sanitation Program: How to communicate with owners/operators/workers from Chinese Rrstaurants who do not speak or understand English well?
Area for Improvement:
Only 5 of the 12 workers from Chinese restaurants who attended NRA ServSafe courses in 2009 actually passed to become certified.
Root Cause:
The QI tools and focus group clearly identified the language barrier as the root cause for the low ServSafe passing rate among Chinese food service workers.
Planning and Execution Details
QI Implementation:
GTCHD created a process map to outline the current process for scheduling students for a ServSafe course and exam. Using the process map, the GTCHD
QI Team identified the following problem areas:
There is no standard policy for identifying specific needs regarding language or disability. Even though students may request a non-English book and exam, the course is only offered in English.
No translator available for Chinese food service workers to ask ServSafe instructor questions from textbook.
No follow-up survey for students to measure course and exam quality.
Little follow-up for students who failed exam to determine root cause (no follow-up for Chinese students).
GTCHD employed a fishbone (cause-and-effect) diagram to determine possible causes of the low ServSafe exam passing rate among food service workers from Chinese restaurants. The most significant factor was identified as communication problems between GTCHD staff and Chinese restaurant staff due to language barriers. During this exercise, it was apparent that many assumptions were made regarding issues within the Chinese restaurants. GTCHD decided that a focus group of restaurant owners/managers would be helpful to determine the perspective from our clients viewpoint. The GTCHD QI team held a focus group meeting for owners/operators of Chinese restaurants on June 22, 2010. The meeting began with a welcome and introduction period. Once the group was comfortable, the QI team presented the current status of food safety training for Chinese restaurants, including the low ServSafe passing rate among Chinese students. One of the restaurant owners speaks English fluently and was able to act as interpreter between the QI team and the other owners/mangers. There was much discussion regarding the demographics of Chinese food service workers and ways to communicate.
The QI team presented the focus group with an exercise known as the Nominal Group Technique (NGT), which is used to prioritize and generate a course of action. The NGT exercise started with posing a question pertaining to problems that exist regarding food safety training for Chinese food service workers. Each focus group member was polled to answer the question, and then the answers were listed on a large dry-erase board. Each group member was asked to prioritize each of the answers using a ranking system. The figure below illustrates the results of the NGT exercise in order to further identify the root cause, an interrelationship diagraph was employed to study the cause-and-effect relationship between prioritized answers from the NGT exercise. The answers from the NGT exercise were arranged in a circle, and then a line was drawn between answers if a relationship exists. Next, an arrow was drawn on the line pointed to the item that is most affected by the other. The number of arrows going in and the number of arrows stemming from each cause were counted. The factor or cause with the most outgoing arrows is ranked the highest. In this case, the cause “No Training in Chinese” was ranked the highest and correlates with results of the other tools used to identify the root cause of the low ServSafe passing rate. “Small Labor Force” was also identified as a cause that has significant influence on the other factors. However, the problem of a small labor force is not a factor that can be controlled by GTCHD; therefore, the QI team focused on the issue of “No Training in Chinese.”
The aim statement was revised to account for the findings regarding the root causes. The GTCHD QI team identified potential solutions based on root cause analyses and focus group data. The QI tools and focus group clearly identified the language barrier as the root cause for the low ServSafe passing rate among Chinese food service workers. One potential solution was evident in order to meet the requirements of the AIM statement: Structure a ServSafe course specifically for Chinese food service workers. The following criteria would be key components of the improvement:
1. Teach the course in Simplified Chinese (Mandarin) using a Chinese instructor or interpreter.
2. Structure the course to meet the needs of the student’s busy schedule.
3. Provide the course, Chinese textbook, and Chinese exam free of charge to encourage all area Chinese restaurants to participate by sending as many employees as possible.
The GTCHD QI team developed an improvement theory to increase food safety knowledge among Chinese food service workers. The outcome of the improvement theory is described as follows:
If GTCHD provides a ServSafe course that is taught using the Simplified Chinese language by means of a Chinese instructor/ interpreter, Chinese text books, and Chinese exam forms, then Chinese FS workers will demonstrate a 20% increase in the ServSafe exam passing rate.
If GTCHD schedules the Chinese ServSafe course on a Monday and Tuesday, which are slow days for Chinese restaurants, then the number of potential students will be maximized.
If GTCHD offers the Chinese ServSafe course free of charge, then Chinese restaurant owners will be more likely to send kitchen staff to the training. In order to test the theory, GTCHD planned a Chinese ServSafe course and exam.
The GTCHD QI team searched for a Chinese ServSafe instructor. Availability of a certified ServSafe instructor who teaches the course in Chinese was minimal. Also, the instructor who was available charged a significant amount of money for services. As recommended by the QI team’s mentor, GTCHD contacted Jean Chang, Epidemiologist from Public Health Muskegon County, to inquire about interpretation services. Jean Chang speaks Chinese and English fluently and recently helped teach a Chinese ServSafe class for Muskegon County Chinese restaurants. Jean agreed to assist GTCHD with a Chinese ServSafe course.
GTCHD collaborated with Dorothy Wicks, Genesee County Health Department Environmental Health Supervisor, who provided GTCHD with a professionally produced DVD of a Chinese ServSafe course hosted by Genesee County Health Department and taught by Sheree Lin, PhD, a certified ServSafe instructor.
The GTCHD QI team scheduled a special 2-day Chinese ServSafe Course for Monday, August 30, and Tuesday, August 31, 2010. The 2-day course structure was based on successful Chinese ServSafe courses offered by Genesee County Health Department and Public Health Muskegon County. Also, Monday and Tuesday were selected based on the recommendation of the Chinese Restaurant Focus Group that those days were the best to conduct training due to low customer volume in the restaurants. GTCHD developed a flyer advertising the Chinese ServSafe Course and had it translated into Simplified Chinese (Mandarin). The flyer was hand-delivered to all the Chinese restaurants in Grand Traverse County 6 weeks prior to the course. Also, the flyer was sent to all neighboring health departments and a message regarding the class was sent to the Environmental Health Directors e-mail listserv. Despite the advertisement and follow-up visits and phone calls to area Chinese restaurants, only eight students signed up for the class. The ServSafe textbook was distributed to the students 3 weeks prior to the course.
The Chinese ServSafe course proceeded using a combination of the Chinese ServSafe video presentation and live discussion and review with Jean Chang. Also, the GTCHD ServSafe instructor, Tom Buss, interacted with the students using Jean Chang as the interpreter. Most of the students were engaged in the class discussions and asked questions tailored toward individual experiences and situations.
QI Methods:
Other QI tools:
Morphing Diagram, Focus Groups, Venn Diagram
Initiative Dates:
5/1/10 to 3/31/11
Initiative Duration:
Between 6-12 months
Methods of evaluation:
After the survey was developed, it was then translated into Chinese by Jean Chang, Public Health Muskegon County. The surveys were hand-delivered to each student and then collected 2 days later with a 94% return rate. The answers to each survey question were compiled into six separate categories:
those who passed the English version of the course; those who passed the Chinese version of the course; those who failed each version of the course; those who passed overall; and those who failed overall. In an effort to find common factors, a Venn diagram was constructed to compare those who passed the exam and those who failed.
An examination of the Venn diagram outlined similarities and differences between the two groups. The QI team focused on the unique differences highlighted by the diagram. The fact that all those who passed were owners or managers indicates that “vested interest” may be a significant factor that can be linked to other factors identified such as study habits and work hours per day. Cultural differences or social class issues may be an issue that is not apparent on the surface. Anecdotal information obtained from informal discussions with restaurant owners and discussions during the focus group indicated that many of the Chinese food service workers come from poor rural areas of China with minimal educational opportunities. In fact, the QI team interpreter, Jean Chang, revealed that handwriting and grammar skills of those students who failed the ServSafe exam were generally more basic and elementary than those who passed the exam. These observations are difficult to confirm, but the combination of low education level and low vested interest may be a significant root cause of the low ServSafe passing rate. Vested interest may be a more significant variable than low education level. Some states require that all food service workers have a current “food handler’s card,” which is obtained after passing an approved training program. Workers then have a vested interest in passing the training course because their job is in jeopardy. Vested interest then overcomes the education disparity. The food service worker will take extra measures to pass the course (e.g., seek a tutor, study harder, form study groups, etc.). In Michigan, the food code only requires the person in charge to be certified. In order to effectively increase vested interest among Chinese food service workers, an incentive must be present.
Other Information:
The information gathered at focus groups with owners/operators of Chinese restaurants revealed the following information:
• Chinese workers are preferred over Americans because Chinese workers are proficient in a particular style of cooking using very hot woks and sharp knives for cutting.
• The Cultural Revolution took place from 1966 to 1976, resulting in a lack of education in China. There were either no schools or very poorly run schools, so children were not educated well during that time. Many people working in Chinese restaurants were of school age during this time.
• According to Henry (of China Fair), Simplified Chinese is the primary language that most of them read. The older generation can read Traditional, but the younger generation can only read simplified. Simplified utilizes simple characters, while Traditional is much more complicated to read and is more drawn out.
• When asked what would help regarding food safety training and understanding, they said that having the lessons in Chinese would help. They do not, however, have time to read the whole book because the owners of these restaurants have to work all the time, unlike owners of American businesses.
• They said they have difficulty understanding even the translated versions because they are translated from English to Chinese, and the words do not translate the same when they are read.
• They said they have an understanding of the basics regarding food safety, but much of the information in the book goes very in-depth, and they struggle to understand it.
• When asked if language was the biggest barrier to them passing ServSafe and to learning food safety techniques, they said yes, it is language.
• They suggested having posters that could be hung in their kitchens for employees that were in both English and Simplified Chinese.
• Many Asian workers can read English even if they cannot speak it. English is taught in school in China from a young age, but spoken English is not retained.
• They suggested putting the Health Department logo on all of the posters so that they will be taken seriously.
• They all agreed that administering a survey to all Asian restaurants to gather more data would be fine. They would be willing to review the survey and any literature that GTCHD assembles to make sure it makes sense.
Problems Observed During ServSafe Course:
• Two of the students only attended the second day of the course. They missed 6 hours of the 8-hour ServSafe course format.
• One of the students was a last-minute substitution for a student who had a family emergency in another state. The substitute student did not have an opportunity to study the text book in advance.
• Most of the students had a difficult time understanding and completing the initial personal information required on the exam “bubble sheet.” This fostered a concern that the students may have problems transferring answers to the exam form correctly.
• The exam results indicated that one of students received zero points. This only confirmed that at least this particular student had trouble with the “bubble Sheet” exam form. GTCHD had the student come back and take the exam again, but the student received 73% and failed.
• The small class size magnified any variation; therefore, the statistical significance of the theory test is questionable. However, the mitigating factors must be explored.
Supplemental Materials:
Sample of materials produced
Initiative photo(s)
Report
Storyboard
Supplemental Files:
| Attachment | Size |
|---|---|
 GTCHD Story Board - final2.pub | 933.5 KB |
 GTCHD MLC-3 Final Report.pdf | 1.19 MB |
 Chinese ServSafe 006.jpg | 352.36 KB |
| Chinese ServSafe 029.jpg | 302 KB |
| Chinese ServSafe 043.jpg | 309.21 KB |
Results
Measurable QI Outcomes:
Three out of eight students passed the Chinese ServSafe exam, which yielded a 37.5% passing rate.
The course results did not meet the GTCHD QI team AIM Statement requirement of a 62% passing rate or higher.
Other QI Outcomes:
One of the most significant outcomes of this project is the paradigm shift that has occurred within the QI team. Team members can no longer simply speculate or assume the origin of problems within their respective public health programs. Everything is now viewed through the lens of QI.
Lessons Learned, Observations and Insights:
Initially, the effort to increase the ServSafe exam passing rate among Chinese food service workers seemed like it was going to be black and white.
Provide training in the students' native language, and they will be more likely to pass the exam. In reality, this QI project is not black and white but several
shades of gray. The complexity of the potential root causes and their interrelationships have been both enlightening and perplexing.
Initially, the GTCHD QI team was extremely disappointed to not meet the aim statement and have an "unsuccessful" QI project. However, after further study, there was a realization of positive accomplishments and potential for real improvement. The QI team did succeed in improving the relationship between the health department and the owners/managers/food service workers from Chinese restaurants. The GTCHD's clients were genuinely pleased with the efforts to help them succeed. Also, a foundation of knowledge has been built regarding the cultural differences and complex relationships with Chinese restaurants. Truly, the needs of food service workers from Chinese restaurants are better understood now more than ever. Obviously, there is still much work to be done to achieve the ultimate goal of improving food safety in Chinese restaurants. Great potential exists to build on the accomplishments and make some real improvements in the future to turn this experience into a true "success."
Future Plans:
At this point in time, it is apparent that before any future plans are established, more work must be done. Also, the ultimate goal of increasing overall food safety knowledge and lowering the incidence of food borne disease must be paramount. Therefore, the following initial steps will be forthcoming:
Meet with the Chinese restaurant owners and managers to present the findings of the QI project and discuss potential options for training.
Determine possible incentives for Chinese food service workers to participate in food safety training (i.e., increase vested interest).
Establish AIM statement for new Plan-Do-Study-Act (PDSA) cycle.
The QI team identified three steps to insure that QI continues and grows within the organization: (1) Establish a committee within the administrative team to develop a department policy regarding QI. (2) Establish a work plan to train supervisors, coordinators, and professional staff within specific programs. (3) Develop and prioritize future QI projects within the GTCHD. Mentor the staff involved.
Training and Preparation
Technical Assistance Received:
The MLC-3 project used a mentoring approach for all the teams involved. The mentor for Grand Traverse County was a previous QI project team leader. Also, an MPHI consultant provided mentoring. Mentors were available by phone and e-mail throughout the project. In addition, at least two face-to-face meetings with mentors occurred.
QI Related Training Received:
MPHI provided a 2-day learning session for team members. Also, several webinars were conducted by MPHI to provide further training.
Information about the Community
Population Size:
Population Characteristics:
Grand Traverse County is a county in the U.S. state of Michigan. As of the 2010 Census, the population was 86,986. Grand Traverse County is considered to be part of Northern Michigan and the Traverse City Micropolitan Statistical Area, which also includes Benzie, Kalkaska, and Leelanau counties.
Grand Traverse County’s population grows by approximately 10,000 during the summer, when seasonal homes are occupied. In addition, thousands of tourists visit the area during the summer.
Information about the Health Department
Local Health Department Governance:
Local Governance - all LHDs in the state are units of local government
PHAB Accreditation Status:
Not planning to submit application in the next 3 years
State-based accreditation?:
Yes
Accreditation Date:
8/1/12
Annual QI Initiative Frequency:
QI activity level:
Organization Type:
QI Staff Information
Total number of Staff on QI Team:
4
Total number of FTEs on QI Team:
1.00
QI team members:
Role in the Initiative:
Team Leader
Name (Optional):
Dan Thorell
Role in Organization:
Environmental Health Manager
Name (Optional):
Tom Buss
Role in the Initiative:
Plan Stage Team Member
Role in Organization:
Community Outreach Coordinator
Name (Optional):
Jeannine Taylor
Role in the Initiative:
Plan Stage Team Member
Role in Organization:
Personal Health Administrator
Name (Optional):
Lisa Peacock
Contact Information of the Submitter
First Name:
Daniel
Last Name:
Thorell
Organization:
Grand Traverse County Health Department
Submission Status:
Completed
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Comments
Additional interventions
Thanks for sharing your work. Your future plans sound quite interesting, and I'm wondering if you've been able to make any progress in developing incentives that promote a vested interest? You also talked about developing another aim statement, and I'm wondering what that is/was? There were many interesting items under "other information" - has any of this information been used to develop additional interventions? I look forward to learning more about your work!
Additional work with Chinese food service workers
Thanks for your questions and comments. To date, EH staff with Health Department have not been able to continue with this project. Basically, staffing, funding, and several changes within the Department have prevented additional work. However, the food service inspectors have learned from the project and adopted methods of teaching food safety when doing inspections. This translates to more basic food safety information in simplified Chinese and more hands on training. The Department does plan on conducting a Chinese version of our "Food Safety Basics" program. Our new aim statement would center around this training which we would hire a translator to help teach the class in simplified Chinese. There would likely be a pre-test and a post-test for the class so that improvements could be measured. The class would cover the basics of food safety with heavy emphasis on hands on training and visual aids. Regarding vested interest, we have not worked on that issue. Perhaps the theme for the next focus group.
Daniel R. Thorell, M.S., R.S.
Environmental Sanitarian
Grand Traverse County Health Department
Environmental Health Department
2650 LaFranier Rd
Traverse City, MI 49686
Thank you for submitting this
Thank you for submitting this project. We are currently writing a grant for a QI project to improve efficiencies and effectiveness (communication and customer service) with non-English speaking operators and ESL operators.Your work will help to inform our own.