Strengthening Equity Through Food Safety

Summary

Impact Statement:

The Whatcom County Health department found that language and cultural barriers were contributing to higher numbers of critical Food Code violations for the almost 18% of non-English and ESL food service operators in Level 3 establishments in the County. The department considered the food service operators as “customers”; determined that lack of understanding of the food code was the root cause; and is now testing the impact of providing the materials in 8 different languages on the number of critical Food Code violations.

Summary:

In 2014, Whatcom County Health Department's (WCHD's) Food Safety Program developed a quality improvement (QI) project to improve communication with non-English-speaking or English as a Second Language (ESL) food service operators in the community. The project team sought to improve communication with these operators.

Initially, the project team analyzed quantitative data and collected and summarized "voice of the customer" data by conducting 16 interviews with food service operators in languages other than English. The project team found that 17.8% of the Level 3 food establishments have non-English-speaking or ESL operators. In addition, 50% of those interviewed indicated that language creates barriers that make it difficult for the operator or staff to comply with the food code or understand the food inspectors' instructions.

The project team is currently implementing these interventions and collecting data to determine whether the QI interventions improve the success of non-English-speaking and ESL food service operators in complying with the food code, thus reducing red violation points in Level 3 food operations.

Organization that conducted the QI initiative:

WCHD

Citation:

Sloan, S. Public Health Quality Improvement Exchange. Strengthening Equity Through Food Safety. Fri, 08/14/2015 - 14:28. Available at https://www.phqix.org/content/strengthening-equity-through-food-safety. Accessed December 7, 2023.

Background and Aim

Aim statement:

The project's aim statement is to reduce by 30% the number of red food code violations by non-English-speaking/ESL food service operators in Level 3 establishments by December 31, 2015. Red violation points are the most serious type of food code violations, and Level 3 food establishments have the most complex food preparation challenges. In the long term, the project team will increase Food Safety Program efficiencies (money and time spent) and improve effectiveness (communication and "voice of the customer" service) with non-English-speaking and ESL food service operators. Please note that measurement of success is possible only when the proposed interventions have been implemented for at least 1 year, because establishments are inspected only periodically, and only 17.8% of Level 3 establishments have non-English-speaking or ESL food service operators. Also, as the project was implemented, it became apparent that the project team would not be able to improve efficiencies (money and time spent) until better results had been achieved with non-English-speaking and ESL operators. Initially, a larger investment of money and time was required.

Need For The QI Initiative:

Managers and supervisors chose "improving restaurant efficiencies" as the top WCHD QI priority on September 4, 2012, during a cross-divisional QI training. Also, Food Safety Program staff identified improving communication with non-English-speaking and ESL food service operators as a top program priority. Finally, the work is congruent with the agency's strategic goal of incorporating principles of social justice and health equity into day-to-day work.

Area for Improvement:

WCHD's Food Safety Program frequently interacts with food service operators who have limited or no English proficiency. Although WCHD uses translation services, these services have not always been adequate when translating the highly technical food code. The WCHD Performance Management Team—in partnership with the Health Equity Team—identified improving services to this population as a top QI priority. The mission was to increase Food Safety Program efficiency and improve effectiveness with non-English-speaking and ESL food service operators. Food inspectors for WCHD had long suspected that red violation points were higher with operators who were not proficient in English. Therefore, a first step in the project was to verify that this was indeed the case.

Root Cause:

The project team did not use a specific tool to identify a root cause per se. They used the observations of food inspectors: non-English-speaking and ESL food service operators "seemed" to have higher red violation points. The project team then verified these observations by doing a quantitative analysis of 2 years of data, producing the result/verification that those operators with limited English proficiency had 1.5 times the number of red violation points as English-speaking operators (27.79 vs. 18.33).

Planning and Execution Details

QI Implementation:

This initiative is still in progress. The project team first defined the initiative using a project definition document. They then made a flowchart of the food inspection process to ensure that they understood it thoroughly. They made a Suppliers, Inputs, Processes, Outputs, and Customers (SIPOC) diagram to understand the full dimensions of the Food Safety Program. In addition to verifying that food service operators with limited English proficiency had higher average (mean) red violation points, the project team went directly to these operators and did an in-person survey using translators. Understanding the "voice of the customer" was a primary focus of this initiative. Although the quantitative data verified that these operators were not doing as well as English-proficient operators in complying with the food code, the project team wanted to know the operators' perceptions of why that might be the case. The project team specifically asked (separately) whether culture or language might be a barrier to the operators' ability to comply with the food code. Of interviewees, 33% responded that culture is a barrier, and 50% responded that language is a barrier. The project team attempted 23 interviews and completed 16 (4 in Korean, 4 in Spanish, 3 in Punjabi, 2 in Chinese, and 3 in other languages). The project team and staff of food safety inspectors then gathered for a 1.5-day Kaizen event that was facilitated by an outside consultant who is an expert in Lean/Six Sigma and Kaizen. A Kaizen event provides concentrated time to work on the progressive betterment of a particular problem—in this case, improving communication with diverse food service operators, thereby reducing red violation points and ultimately improving food safety in the community. WCHD's Kaizen event resulted in an extensive list of items to implement in the Gemba ("the real place" where the work is done). The key implementation strategies to address the problem are (1) to print, laminate, and distribute U.S. Food and Drug Administration Oral Culture Learner Project materials (available in eight languages) and (2) to use on-site interpreters when red violation points need correction in establishments in which operators are not English proficient. Many other ideas came out of the Kaizen event, and those are summarized in the Kaizen action plan document attached to this submission. The consultant also produced a fun video to document the event: http://vimeo.com/96032474. The team is currently implementing the key strategies.

Focus activities

Regulation, inspection and/or licensing :

Food service establishments

Administration:

Customer Service/satisfaction

Quality Improvement and Accreditation Readiness

Other QI Focus Activities:

Health equity

QI Methods:

Kaizen

Lean/Six Sigma

PDCA/PDSA Cycle (Plan, Do, Check/Study, Act)

QI Tools:

Brainstorming

Process maps

Other QI tools:

Kanban board

QI Tool Documentation:

This is the survey instrument. The survey was completed during in-person interviews with a translator present.

Food inspection process flow

Project definition document submitted to the WA State Public Health Performance Management Centers for Excellence

SIPOC diagram

Details of the action plan that was generated during the Kaizen event. These items were transferred to a kanban board.

A picture of the project's kanban board used to keep track of "to do," "doing," and "done" items

Initiative Dates:

11/1/13 to 12/1/15

Initiative Duration:

Greater than 24 months

Methods of evaluation:

Once the project team has implemented the key strategies, they will collect, analyze, and report post-implementation average (mean) red violation points after the changes are initiated. The project team also intends to re-survey the non-English-speaking and ESL food service operators to gather additional input on how the project team might more effectively support their success in complying with the food code. The project team would also like to do a return on investment analysis.

Strengthening Equity Through Food Safety

Summary

Background and Aim

Planning and Execution Details

Results

Training and Preparation

Information about the Community

Information about the Health Department

QI Staff Information

Contact Information of the Submitter

QI Spotlight

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Strengthening Equity Through Food Safety

Summary

Background and Aim

Planning and Execution Details

Results

Training and Preparation

Information about the Community

Information about the Health Department

QI Staff Information

Contact Information of the Submitter

QI Spotlight