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Implementation of a Pilot Program to Address Reliability of Environmental Sanitation Inspections at Memphis and Shelby County Health Department 2008-2009

Environmental Public Health Leadership Institute Fellow(s):

Tyler Zerwekh, MPH, DrPH Deputy Administrator, Environmental Health Bureau; Memphis and Shelby County Health Department 814 Jefferson Ave., 502H Memphis, TN 38105 901-544-7734 [email protected]

Mentor(s):

Greg Kearney; MPH, DrPH, RS Environmental Epidemiologist Florida Dept. of Health, Division of Environmental Health Environmental Public Health Tracking 4052 Bald Cypress Way, Bin A#08, Tallahassee, FL 32399 (850) 245-4444 x4577

(Acknowledgements):

Yvonne S. Madlock, MAT Director, Memphis and Shelby County Health Department

Norman LaChapelle, MSPH, RS, RPH Administrator, Environmental Health Services, Memphis and Shelby County Health Department

2008–2009 Fellow Project National Environmental Public Health Leadership Institute 230 EXECUTIVE SUMMARY:

The Memphis and Shelby County Health Department (MSCHD) became aware of poor quality sanitation inspections during a recent state health agency audit. A disconnect between quality inspections was speculated to be attributed to poor managerial and administrative decisions by the Sanitation manager to the environmentalists, which therefore caused uninspired work by the environmentalists. Through the creation of a novel quality assurance pilot program, the EPHLI fellow implemented a system to assist in increasing accurate and representative sanitation inspection surveys. The proposed program would consist of unannounced and regular (6 per quarter) inspections by a lead environmentalist immediately after the initial inspection with escalating discipline for non-compliance. While executing this program Sanitation management alleviated some of their administrative policies to encourage individual responsibility and ownership of inspections upon the environmentalists. In unveiling the program, it became evident the lack of quality inspections was not due to lack of training on behalf of environmental specialists, but a “perceived” lack of professionalism and responsibility bestowed to the specialist on behalf of the manager. Once the manager released authoritative duties to the specialist, inspections scores immediately began to decline and became more representative of the true sanitation score of the facility. However, one drawback to the implementation of the pilot program was the development of accidental adversaries from restaurant operators who perceived more stringent inspection practices, which fractured the operator/environmental relationship. This loop can be minimized through effective standardized training and routine and repetitively similar inspections. In summary, a pilot program is a unique methodology in addressing fundamental deficiencies in quality sanitation inspections.

INTRODUCTION/BACKGROUND:

Memphis and Shelby County Health Department (MSCHD) is a joint funded agency of County and City governments. Shelby County contains seven incorporated municipalities (e.g., Memphis, Arlington, Bartlett, Collierville, Germantown, Lakeland, and Millington) and several unincorporated areas. Shelby County is also the largest county in the State of Tennessee, both geographically (approximately 783 square miles) and in population (909,035).

With over 5,000 food establishments throughout Memphis and Shelby County, MSCHD is required by both Tennessee Department of Health and Tennessee Department of Agriculture annotated law to inspect facilities twice per year, and more often if critical sanitation violations have been cited or if there are food-borne outbreaks or food-borne complaint investigations.

The association between environmental sanitation inspections and food-borne outbreaks in communities has been documented extensively (1). With only seventeen environmentalists trained at MSCHD to perform sanitation inspections on the 5,000+ facilities, it is not uncommon for an environmentalist at MSCHD to perform over 700 inspections and follow-ups in one calendar year. The sheer amount of inspections by environmentalists’ can lead to practices that ultimately compromise the integrity of an individual inspection to satisfy the overall arching goal of total inspection completion. During a recent audit investigation by the Tennessee Department of Health (TDH) on the MSCHD Environmental Sanitation division, it was documented that

2008–2009 Fellow Project National Environmental Public Health Leadership Institute 231 unannounced inspections by TDH immediately after a MSCHD inspection yielded an average difference score of 35 points with a range of one to five critical violations not documented by MSCHD environmentalists but observed and documented by TDH audit staff.

The significance of these findings has immediate environmental public health ramifications on Shelby County, TN, and its stakeholders. Inaccurate and underscored inspections increase the likelihood for a facility to continue practices and controls deemed unsanitary and unsafe. This can lead to an increased risk in unsafe food and food handlers, which ultimately leads to a higher probability of food-borne and infectious disease transmission to facility patrons. This project will focus on the development and implementation of a sanitation pilot program that aims to increase the accuracy and reliability of environmental sanitation inspections within the MSCHD Environmental Sanitation Section.

Problem Statement: Implementation of an environmental sanitation inspection pilot program to address reliability, validity, and repeatability results for a comprehensive environmental sanitation program, which will provide accurate and representative sanitation scores of operator facilities to Shelby County stakeholders.

The Environmental Sanitation program is designed to be proactive and population-based in nature. Activities are primarily directed by surveillance and are data and science-based driven. Implementation required input and participation by a variety of stakeholders with mutual interests and investments. Collaboration and communication among stakeholders were key factors to establishing and building environmentalist and community ownership. To ascertain maximum involvement, the following stakeholders from the community were identified: (1) residents within Shelby County, (2) MSCHD Administration, (3) MSCHD Environmental Sanitation management, (4) MSCHD Environmentalists, and (5) Tennessee Department of Health Environmental Sanitation Division. MSCHD Lead Environmentalists and Supervisors were tasked to perform six random follow-up unannounced quality assurance inspections per quarter (calendar year) on each environmentalist to verify inspection score validity. Reliability and accuracy in the program was increased as control operations were executed on a standardized basis.

2008–2009 Fellow Project National Environmental Public Health Leadership Institute 232 Changing Inspection Behavior Not Changing Inspection Behavior Benefits Increased quality of food consumption Environmentalists continue with Decreased incidence of food-borne illnesses minimal workload and outbreaks Status quo Efficient inspection process Inspection quotas are met Additional encouragement and acknowledgement by management and community

Costs More work on behalf of environmentalists Increased food-borne illnesses More interaction (good or bad) and perception Vicious cycles on behalf of of accusations / unfair practices to restaurants environmentalists performing More work for audits quality assurance inspections inspections by lead staff Environmentalists don’t have to change behavior No long term improvements in inspection process No opportunities for additional training that is meaningful

The benefits of not changing and the costs of changing keep the system the same because there is complacency bred on behalf of the environmentalists who do not want to add additional work to their workload. It also allows the environmentalists to continue to meet their inspection quota, despite the decreased quality of inspections being performed. It also allows the leads to not have to incur additional work by performing quality assurance inspection audits. The solution was to minimize the strength of the above factors while building up change, and to stress the items of benefits of change and the costs of not changing. Almost like a balance system, it is easier to prevent the positives then to punish or enforce the negatives of any problem. This allows for the reinforcement of the vision of quality inspections without having to perform quality assurance audits on each and every environmentalist.

2008–2009 Fellow Project National Environmental Public Health Leadership Institute 233 Behavior Over Time Graph:

MSCHD Environmental Sanitation Inspection Program

4

G

G

1 a

a

p

p

2

1

Variables 2

3

Time

1 = Number of Restaurants increasing over time within the community 2 = Community concern for delivery of effective environmental public health services 3 = Environmental Public Health service delivery (Sanitation inspection quality/consistency) 4 = Capacity for development / training

2008–2009 Fellow Project National Environmental Public Health Leadership Institute 234 Causal Loop Diagrams and applicable Archetypes:

Shifting the Burden

Qu ic k Fix: Tim e Sp e n t a n d Re so u rc e s

Symptom Correcting B Problem Symptom Process

Side Ef f e c ts: Failing to m e e t m o n thly in spection q u o ta s a nd ‘cuttin g Quick P o o r q u a lity o f c o rn e rs’ d u rin g Sa n ita tio n in sp e c tio n p roc ess to Fixes I n sp e c tio n s a n d R m e e t th e ir q u ota a t the P re ssu re to Me e t la st m in u te Qu o ta s Long Term Solutions Cause B Side Effects Correcting Undermining Process Efforts to Address Ca p a c ity de ve lo p m e n t. Fundamental Time Fo r tra in in g Be tte rs I n sp e c to rs Issue m e e t Qu o ta s

2008–2009 Fellow Project National Environmental Public Health Leadership Institute 235 Shifting the Burden: Interventions

1. Quality inspections ultimately increase Quick Fix - efficiency while decreasing Time Spent and Resources time spent and resources Allocated allocated. and used ??? 2. Better trained inspectors understand and implement quality inspections while maintaining quality BB 1 assurance integrity and quota standards. X 3 3. Cannot implement the Poor Quality of quick fix to build…creates Sanitation Side Effect — Inspections & Failure vicious cycles. To meet inspec. R quotas

B X 2

Long Term Solution Desired Vision Capacity development 2 for training. Better inspectors meet quotas www.appliedsystemsthinking.com

2008–2009 Fellow Project National Environmental Public Health Leadership Institute 236 Accidental Adversaries

Sa n ita tio n m a n a g e r in vo k e s p ro c e sse s to h e r lik in g th a t a llo ws f o r sa n ita ria n to in sp e c t re sta u ra n ts in a n in c o m p le te f a sh io n . R

Elic it a re wa rd D e p rive s Sa n ita ria n s o p p o rtu n ity Sa n ita tio n m a n a g e rs p ro g ra m to e n c o u ra g e to dive rsif y wo rk p la c e sk ills m e e ts re sta u ra n t B q u a n tity o ve r q u a lity wh ile m in im iz e s jo b in sp e c tio n q u o ta s in sp e c tio n s, p a y ra ise s, m a rk e ta bility . Cre a te s p o sitive p e rf o rm a n c e re du n da n c y in in sp e c tio n p ro c e ss re vie ws

R

N o f o ru m / a ve n u e to Co n tin u e to ra tio n a liz e d isc u ss o r im p le m e n t n o c h a n g e f ro m c h a n g e in in sp e c tio n q u a lity m a n a g e m e n t to ju stif y B Sa n ita ria n s m e e t in sp e c tio n o r e f f ic ie n c y m e dio c re in sp e c tio n . I n c re a se s in sp e c tio n q u o ta s. Re c e ive p ro te c tio n f ro m q u a n tity wh ic h m e e ts m a n a g e r f o r a dh e rin g to h e r m a n a g e r g o a ls p o lic ie s a n d stu bbo rn n e ss to c h a n g e

Sa n ita ria n s o p p o se a n tiq u a te d a n d re du n da n t in sp e c tio n s te c h n iq u e s y e t k e e p m a n a g e r h a p p y b y p e rf o rm in g th e m in th e m a n n e r th e y a re re q u e ste d

2008–2009 Fellow Project National Environmental Public Health Leadership Institute 237 10 Essential Environmental Health Services: In 2002, the Institute of Medicine released “The Future of Public Health in the 21st Century” that defined and reaffirmed the 10 Essential Environmental Health Services and/or the three (3) functions described in this project: assessment, policy development and assurance.

Figure 1: Ten Essential Public Health Services

Source: Public Health Functions Steering Committee (September, 2002)

National Goals Supported This project seeks to support at least one or more of the Healthy People 2010 Objectives http://www.cdc.gov/nchs/about/otheract/hpdata2010/abouthp.htm .

Objective 10-1 – Reduce infections caused by key food-borne pathogens by refining and capturing accurate sanitation scores of restaurant facilities to minimize recurring practices that facilitate and catalyze proliferation of food-borne pathogens within the facility.

2008–2009 Fellow Project National Environmental Public Health Leadership Institute 238 Objective 10-6 – (Developmental) Improve food employee behaviors and food preparation practices that directly relate to food-borne illnesses in retail food establishments by executing accurate and reliable sanitation inspections that incorporate hygienic and safe food practices for food service employees.

This project addresses the following essential Environmental Public Health Services:

1. Monitor the environment and health status of the community to identify environmental health problems such as food-borne outbreaks 2. Diagnose and investigate environmental health problems and health hazards in the community 3. Inform, educate, and empower Shelby County residents and restaurant operators about environmental health (sanitation) issues in the community by making presentations to increase public awareness of sanitation regulations and practices. Empower municipalities through collaborative efforts. 4. Enforce laws and regulations to ensure the health and safety of residents, stakeholders, and visitors of Memphis and Shelby County. 5. Assure a competent environmental health workforce by hiring and training internal and external staff. 6. Evaluate the effectiveness, accessibility, and quality of personal and population based environmental health services.

2008–2009 Fellow Project National Environmental Public Health Leadership Institute 239 Project Logic Model Goal: To implement a program for the Memphis and Shelby County Health Department (MSCHD) Environmentalists that will aim to increase repeatability and efficacy for Sanitation Environmentalists across their specific discipline training. Resources/Inputs TIER I Activities Outputs Short & Long Term Outcomes, Impacts. Identification of Pilot Q/A Program  Research various training programs Learning  # of facilities inspected  CDC  Engage staff  Increased capacity of environmentalists  # of Q/A inspections per  State Health  Develop objectives to provide inspections in respected Environmentalist Agency  Develop policy discipline  # inspections per time period  MSCHD Env.  Select and standardize auditors  Improved delivery of inspection  Environmentalist inspections Health staff  Increased number of envrionmentalists’ audited  Increased collaboration within Behavior environmentalists and their programs  FDA  Training needs are correlated to core  Increased  TN State Environmental PH competencies desire to Law  Increased matching of learning needs perform with training curriculum being offered efficient and efficacious Training Environmentalistsinspections Learning Conduct pre-inspectionwithin trainings  PH leadersConduct assess Q/A individual inspection efficiency training  # individual assessments discipline and repeatabilitysessions capacity  # persons trained  PH leadersStandardize gain Behaviorknowledge all trainings and skills\  diversity of persons trained  PH leaders masterchanges core competencies in  #, scope, and focus of trainings environmental  # of eval systems/plans implemented  # evaluations/reports developed  # individuals assessed  #/range of Env. PH competenciess incorporated into assessment

Results  More efficient Partners Learning and effective  Increased #Teamwork of Q/A partnerships pilot and projects Collaborative between PH leaders #Projects of environmentaland communitysanitation leads and involvedbusinesses and in  CDC Q/A Environmental pilot projectsenvironmental Leads submit Q/A  Health  # andpilot focus project ofhealth Q/Aproposals pilot projects Departments  Environmental Leads present  Community projects inspection partners  Environmentalsystem Leads receive  Academic feedback onImproved projects  Final, standardized pilot project selected

2008–2009 Fellow Project National Environmental Public Health Leadership Institute 240 PROJECT OBJECTIVES/DESCRIPTION/DELIVERABLES:

Program Goal To implement an environmental sanitation inspection pilot program to address reliability, validity, and repeatability results for a comprehensive environmental sanitation program.

Health Problem More than 54 billion meals are served at 844,000 commercial food establishments in the United States each year and nearly half of all money spent on food is done so at food establishments. On a typical day, 44% of adults in the United States eat at a restaurant. Approximately 40% of food- borne disease outbreaks reported to the Centers for Disease Control and Prevention are attributed to commercial food establishments. Preventing restaurant-associated food-borne disease outbreaks is an important task of public health departments. Many times, sanitation inspections performed by public health departments at these food establishments are not efficient or reliable when performed due to myriad reasons including, but not limited to, inspector training level, workload, and type of facility inspected.

Outcome Objective The Memphis and Shelby County Health Department Environmental Sanitation program aimed to work with program managers, lead environmentalists, and environmentalist to implement and execute a quality assurance pilot project that would increase the repeatability and accuracy of environmental sanitation inspection scores at sanitation facilities.

Determinant  Tennessee Department of Health program audit determined a difference in 35 points (5 violations, 1 critical violation) on average of facilities audited after a MSCHD Environmentalist inspection

Impact Objective By January 2009, MSCHD Environmental Sanitation program will have implemented and maintained a Quality Assurance Program to ensure sanitation inspection repeatability and accuracy on all sanitation inspections.

Contributing Factors  Increased workload of inspections per environmentalist  Decreasing concern of auditing and/or discipline for poor inspection performance from management  Comfortableness of facility schedule / lack of diversity in inspection schedule

Process Objectives  Establish dialogue with MSCHD Administration and Environmental Sanitation program managers to brainstorm and develop methodologies in approaching discrepancy in audit scores and MSCHD inspection scores.

2008–2009 Fellow Project National Environmental Public Health Leadership Institute 241  Environmental Lead development of potential pilot programs to ensure quality assurance (Q/A) is being met in regular, day-to-day environmental sanitation inspections  Selection of Q/A pilot program  Provide standardized training to environmentalists on inspection process and procedures  Provide standardized training to Lead Environmentalists on audit (Q/A) inspection process and procedures  Provide standardized training to environmentalists on Q/A pilot program  Implement quality assurance pilot program inspection auditing process

METHODOLOGY:

1. Event: Quality Assurance Pilot Program Planning

Activities:  Meeting with Environmental Health Administrator and MSCHD Director of Health to present ideas for increasing repeatability and accuracy of sanitation inspections (June 2008)  Meeting with MSCHD Environmental Sanitation program managers to unveil quality assurance pilot program sanitation inspection audit process and enlist support for the program (August 2008)  Develop a timeline for integration, implementation, and execution of the pilot program (August 2008)

2. Event: Workforce Development and Enhancements – Addressing personnel issues and the increase in expertise through workforce development and technology

Activities:  Assess TDH audit criteria into pilot program training to ensure standardization (August 2008)  Conduct trainings for Lead Environmentalists to standardize audit inspections (September 2008)  Conduct trainings/re-trainings for Environmentalist to standardize sanitation inspections (September 2008)  Reassign inspection “zones” to minimize inspection bias and confounding

3. Event: Pilot Program Implementation

Activities:  Environmentalists’ inspection of facilities  Lead Environmentalists’ audit inspections of random facilities.  Education to operators selected for audit inspections of pilot program  Environmental Sanitation program manager analysis of audit inspections

2008–2009 Fellow Project National Environmental Public Health Leadership Institute 242 RESULTS: 1. A total of 36 facilities were audited for 16 Environmentalists by 3 Lead Environmentalists during the month of December 2008. 2. Results demonstrated an average of 6.11 points lower score when the Lead Environmentalist performed an audit inspection after the environmentalist. 3. The range of difference in sanitation inspection was from 20 points lower to 9 points higher than the Environmentalist when the Lead Environmentalist performed the audit inspection immediately after the initial

CONCLUSIONS:

The results demonstrate the pilot program was unsuccessful upon initial examination. However, it is worth noting that 20% (7 / 36) of the facilities audited did observe the environmentalist scoring the facility lower than the audit procedure done by the Lead Environmentalist after the initial inspection. These results extrapolated demonstrate there was value in implementation of the program, whether it was due to fear/concern the environmentalist would be exposed for poor inspection methodology or because there was an actual observed improvement in the sanitation inspection procedure.

While the results were not favorable, it is worth noting this was the initial audit follow-up analysis for this pilot program and hopefully future audits will demonstrate more frequent and improved reliability and repeatability in environmentalists’ scores and Lead Environmentalists audits. Future steps and next directions include: 1) continued audit inspections to further underscore the importance of proper sanitation inspections, 2) refresher and additional trainings for environmentalists who continue score inspections higher than audit follow-ups, and 3) disciplinary action for environmentalists who continue to underscore sanitation inspections.

LEADERSHIP DEVELOPMENT OPPORTUNITIES:

Tyler Zerwekh

The Environmental Public Health Leadership Institute (EPHLI) has provided me with a new awareness into my leadership skills and style throughout the internship. Through the Meyers- Briggs Type Indicator I was able to determine my exact personality type and refine my strengths in my personality traits while adjusting perceived weaknesses to be revised or amended when a certain leadership style dictated so. Additionally, the Skillscope tool helped me reexamine certain traits and talents that I am strong in while helping me reassess those that needed refinement. As much as I struggled to adopt and enrich myself with Systems Thinking during cohort sessions, I found myself a Systems Thinking approach throughout the past year in professional dilemmas and problems. As I continue to develop and hone my Systems Thinking skills, I know this will be a powerful approach to identifying and solving future problems in both my professional and personal life.

2008–2009 Fellow Project National Environmental Public Health Leadership Institute 243 Most importantly, the EPHLI experiences granted me an opportunity to network and establish professional relationships that had and will have a direct impact on my career. Soon after acceptance into EPHLI, I was promoted into a new position. Upon promotion, I was tasked with a major environmental public health problem under one of programs. It was then I reached out to my cohort and previous cohorts (I – III) for assistance with the work problem. The response was overwhelming, supportive, and immediate! Persons from my cohort and previous cohorts provided immediate feedback and recommendations of not only how to approach the problem but also methodologies that were successful and experiences learned in handling the problem. For this, I am most grateful and appreciative of my EPHLI experience.

2008–2009 Fellow Project National Environmental Public Health Leadership Institute 244 ABOUT THE EPHLI FELLOW(s)

Tyler Zerwekh grew up in Dallas, Texas, the older of two children. Mr. Zerwekh was appointed Deputy Administrator for the Environmental Health Services Bureau for the Memphis and Shelby County Health Department in May of 2008. He is responsible for the administration and day-to-day oversight of four programs under Environmental Health: Pollution Control, Environmental Sanitation, Emergency Preparedness, and Vector Control.

Prior to his appointment, Mr. Zerwekh was the Regional Hospital Coordinator under the Public Health Emergency Preparedness Program for the Memphis and Shelby County Health Department. Before joining Shelby County Government in January of 2007, Mr. Zerwekh spent five years with the Hawaii Department of Health serving different roles under their All-Hazards Preparedness Program; including County Epidemiologist, Bioterrorism Epidemiologist, and All-Hazards Planner.

Mr. Zerwekh received his Bachelor’s in Science in Psychology and Chemistry from Texas Tech University. He continued his education when he received his Masters in Public Health (Occupational Health) and Doctorate in Public Health (Disease Control) from the University of Texas, School of Public Health in Houston, Texas.

2008–2009 Fellow Project National Environmental Public Health Leadership Institute 245 REFERENCES

1. Jones TF, Pavlin BI, et al. Restaurant Inspection Scores and Foodborne Disease. Emerg Infect Dis., 2004 Apr., (10)4:688-92.

2. Goodman, M., Karash, R., Lannon, C., O’Reily., W., and Seville, D. (1997). Designing Systems Thinking Intervention. Waltham, MA. Pegasus Communications, Inc.

3. Senge, P. (1990). The Fifth Discipline. The Art and Practice of the Learning Organization. New York: Doubleday Currency.

4. CDC. A National Strategy to Revitalize Environmental Public Health Services. Atlanta, GA: Department of Health and Human Services. (US) CDC: September 2003.

5. U.S. Department of Health and Human Services. Healthy People 2010. 2nd ed. With Understanding and Improving Health and Objectives for Improving Health. 2 vols. Washington, DC: U.S. Government Printing Office, November 2000.

6. Osaki, Carl, RS, MSPH, Northwest Center for Public Health Practice, 10 Essential Environmental Health Services. (www.cdc.gov/nceh/ehs/Docs/nationalstrategy2003.pdf )

7. CDC Health Protection Goals (www.cdc.gov/about/goals/default.htm )

2008–2009 Fellow Project National Environmental Public Health Leadership Institute 246

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