Enabling Small Local Environmental Health Programs in Oregon to Fulfill Their Role in an Integrated National Food Safety System
Holly Skogley
Linn County Environmental Health Program (Oregon)
International Food Protection Training Institute
2010 Fellow in Applied Science, Law and Policy: Fellowship in Food Protection
Abstract
The purpose of this study was to explore ways for small local environmental health programs to build capacity to assist in fulfilling their critical role in establishing a national integrated food safety system. The capacity related to foodborne illness investigation and emergency preparedness response at the local levels was used as an indicator. Epidemiologic data and completion of Standard 5 of the Food and Drug Administration (FDA) Voluntary Retail Food Regulatory Program Standards (VRFRPS) was used to gauge if local jurisdictions were prepared to respond to outbreaks and emergencies within the national food safety system. Additionally, the structure of Oregon’s retail food safety program was reviewed to determine if capacity-building enhancements could be made using available resources. Discussions were held with stakeholders to explore the level of preparedness within different size jurisdictions, and lessons learned from previous and ongoing attempts to build capacity in other states were considered. A literature search was conducted to identify models to use for a potential pilot project in Oregon to improve the state’s readiness to respond to future outbreaks and emergencies.
Background
In the last 20 years the Oregon food protection program has changed a great deal. Funding and resources have capped out and are now on the decline, costs are skyrocketing, and businesses are struggling in the current economic climate. The 2009 Business Oregon report listed 34 of 36 counties as economically distressed, which are reported counties that exceed 8% unemployment (Business Oregon, 2010). Additionally, the Trust for America’s Health ranks Oregon as 39th in its public health per capita spending; since 2008, local public health departments reported losing 23,000 jobs nation-wide, totaling 15% of the local public health workforce. Despite these negative trends, the public health network, comprised of more than 3,000 federal, state, and local health agencies, is now expected to effectively respond to local public health needs with routine activities, as well as during public health emergencies (Trust for America’s Health, 2011).
Ready or Not 2010, published by the Trust for America’s Health, reports a decade of progress in improvement on how the nation, including Oregon, prevents, identifies, and contains new disease outbreaks and bioterrorism threats, and responds to the aftermath of natural disasters. The report further points out that these gains have only been sustained by recent H1N1 emergency supplemental funding and funding from the American Recovery and Reinvestment Act. These sources of funding are almost entirely depleted and are not expected to be offered again to local health departments in the foreseeable future. The decade of gains is jeopardized due to severe budget cuts by federal, state, and local governments (Trust for America’s Health, 2010).
In Oregon, the state legislature has passed laws governing food service facilities and has given various state agencies rule-making and regulatory authority over these facilities. The state agency overseeing the regulation of restaurants in Oregon is the Oregon Health Authority (OHA) Foodborne Illness Inspection Program (FIIP). Illness investigations are coordinated through the OHA Acute and Communicable Disease Program (ACDP). The OHA enters into contractual agreements with county health departments and health districts to administer the program within their jurisdictions. Over time, the performance standards and contracts between the state and counties have become more prescriptive (Gostin, et al. 2000). The contract that the local jurisdictions sign with the State of Oregon to conduct the food program at the local level is prescriptive in nature. Examples of the prescriptive nature of the program include percentages of time allowed for field activities. Administrative costs, which include clerical support and supervision, are capped at a set percentage of direct costs and services, and add-on fees are not allowed. These restrictions are meant to keep the cost of the local programs in check, and to maintain consistency system-wide. Local programs are allowed to assess specific special fees for additional time related to fulfilling requirements within the contract. For example, plan review is required for new and remodeled facilities. Under the contract, a local program can charge a fee to recover the cost of providing this service (Department of Human Services, 2009-2011). Oregon statutes restrict the use of the funds collected to be used only for services to carry out the requirements of the statutes. The statutes do not address capacity-building, continuous program improvement, and rapid response to emergencies. As part of program support costs, each local entity remits a portion of collected license fees to the state to cover state administrative and oversight costs (Oregon Revised Statutes, 2009).
In the past, food protection components of local health programs have been funded by general funds and supplemented by license fees. However, because revenue available from general funds has decreased, and more public services are competing for dwindling funds, local programs are relying on license fees to run the local programs.
With declining resources and the more prescriptive nature of contractual agreements, the food protection program in Linn County focuses on meeting prescribed outcomes set in administrative rules for annually-licensed facilities such as restaurants and mobile food units. Accomplishing the prescribed activities consumes nearly all of the available fiscal and personnel resources. As a result, proportionally less time is available to perform ongoing program improvement, capacity-building, and preparation for response to food-related emergencies.
Federal and state agencies agree on the need for an integrated food protection system among federal, state, and local levels of government. A key assumption is that the only way to meet the capacity needs for an effective food protection program, coupled with emergency response, is to use the infrastructure already in place. Much of this discussion takes place at the federal and state level (Taylor, et al., 2009). However, there has been limited leadership and operational direction regarding the specifics of how this would be accomplished within the current economic climate at the local level.
Oregon has created a food defense plan as part of the State of Oregon Emergency Management Plan. In the plan, the Oregon Department of Agriculture (ODA) is the lead agency for food defense including the food production system. OHA has a supporting role in assisting ODA and local health departments during response and recovery actions and communication with the public. However, emergency response is primarily a local responsibility, with local health departments responsible for “on the ground” work, including the initial response to possible foodborne illness incidences involving any ODA- and OHA-regulated facilities. When resource capacity is exceeded, the local health department contacts the Emergency Coordination Center. “Exceeding resource capacity” is defined in the food defense plan as a lack of environmental health specialists to conduct response operations (Oregon Department of Human Services, 2007).
FDA has created the VNRFRPS with input from federal, state, and local regulatory officials; industry; trade associations; academia; and consumers. VNRFRPS can be used by agencies to assess gaps in the programs and to guide the development of a program improvement plan. Work on compliance with the standards is supported by regional FDA staff. In Oregon, several local jurisdictions, as well as the state FIIP, are enrolled in the program. Standard 5 addresses the planning and tools needed for local programs to be effective in the jurisdictions’ roles in foodborne illness investigations and food defense preparedness and response (Food and Drug Administration, 2011). The FIIP in Oregon is enrolled in the VNRFRPS and working on compliance with all of the standards except for Standard 5. FIIP is not working towards Standard 5 because the lead program for foodborne illness investigation and response is the ACDP section of the OHA. Although Linn County has been enrolled in the program since 2005, the county has not been able to devote the necessary resources needed to make progress toward attainment of Standard 5.
One potential reason for this failure is associated with the increased cost in providing funded services within local jurisdictions, which are easily outpacing available resources. In addition, local jurisdictions struggle with addressing day-to-day unfunded activities such as oversight of benevolent temporary restaurants, animal bites, technical assistance and consultation with the public, and routine epidemiological investigations unrelated to the facilities the local jurisidctions regulate. Most local jurisdictions do not have the capacity to face a local event such as a large outbreak or flooding incident, let alone a national emergency.
Many of the initiatives to build capacity within local and state health department services are geared towards larger programs that have an infrastructure established that can support exploring alternative funding, alternative resources, and development of approaches to build economies of scale. Also, capacity-building programs focus on training, education, and equipment, and fall short on funding for program maintenance and improvement. After initial resources are exhausted, no additional funding remains to sustain the changes, and programs revert back to the status quo.
If small local health departments (which include most departments) are to be part of any comprehensive initiative to fully integrate the US food protection program, the small local health departments need to significantly develop the local departments’ capacities and expertise, and need to have resources necessary to support delivery of traditional food protection services (e.g., inspections), to implement and sustain continuous program improvement, and to respond appropriately and quickly to food-related emergencies within local jurisdictions. However, with the chronic lack of funding clearly evident, most food protection programs operating primarily at the local county level are not prepared and should not be realistically considered a viable component of a national integrated food safety system.
Research Question
How does the structure of Oregon’s existing retail food safety program impact local jurisdictions’ capacity-building efforts to participate in an integrated national food safety system?
Problem Statement
The purpose of this paper was to address and explore ways for small local environmental health departments to build internal capacity to assist the local environmental health departments in fulfilling the departments’ primary role in a national integrated food safety system (e.g., investigation and response to foodborne illness outbreaks) with minimal capital output by utilizing existing resources provided by state and federal stakeholders.
Methods
A qualitative analysis was done of the structure of Oregon’s retail food safety program to determine if capacity-building could be done using available resources. State statutes, administrative rules, performance standards, and the state contracts local jurisdictions hold to conduct the food protection program locally were reviewed. This review focused on parameters that limit fee collection and flexibility in use of time and resources for operating the food protection program. Additionally, an on-line literature search was conducted for examples of capacity-building activities that are taking place in the United States. This search strived to identify training models that would address some of the capacity-building pitfalls experienced in traditional models. Specifically, the objective of this search was to identify a training model that would build capacity with tangible outcomes that enable local staff to immediately put the training products in use and that have a resource for follow-up support allowing staff to function more efficiently by providing a product or skill that is immediately useable, as well as follow-up support that may be needed to implement training.
Using a phone questionnaire, stakeholder input was gathered regarding the progress of local health departments in Oregon in meeting the FDA VNRFRPS. A request for participation was e-mailed to members of the Council of Local Environmental Health Supervisors representing 36 counties in Oregon. Those council members who responded were sent the questionnaire and additional background information and contacted by phone. Specifically, information was sought on how the state and the state’s local jurisdictions are approaching VNRFRPS Standard 5, Foodborne Illness and Food Defense Preparedness and Response.
Completion of Standard 5 of FDA’s VNRFRPS was used to determine if local jurisdictions were prepared to respond to outbreaks and emergencies within the national food safety system. Foodborne illness outbreak response data was also used to determine if a jurisdiction had a functional and active foodborne illness and response system.
Results
Two counties responded to the phone questionnaire concerning compliance with Standard 5 of the VNRFRPS. One county, Multnomah, is a large urban county in the northernmost part of the state. It includes the largest city in Oregon, Portland. Multnomah County completed Standard 5 and was last verified by FDA in July of 2005. The second county, Coos County, is a small rural county that has made compliance with Standard 5 a priority, and which is close to achieving this goal. In interviewing both counties, the disparity between the large (Multnomah) and small (Coos) counties in terms of resources—both personnel and funding—was apparent. The economy of scale that the larger county possesses, as well as the access to more funding resources through general funds and grants, has enabled Multnomah County to attain compliance with Standard 5 and more when compared to the smaller rural county. Multnomah County has achieved compliance with Standard 5 and created tools that have enhanced foodborne illness surveillance. In Coos County, the goal is limited to basic compliance with Standard 5. This compliance is being achieved by using other jurisdictions’ Standard 5 products and customizing them to Coos County’s local needs. The Coos County model is most applicable to other, less-populated and ill-funded counties. Compliance with Standard 5 in these smaller jurisdictions using this model should be adequate to efficiently investigate and respond to the types and size of foodborne outbreaks reported in these smaller jurisdictions.
The literature search revealed a training model used in North Carolina for building geographic information systems (GIS) capacities at local levels. The North Carolina model was unique in the model’s approach to training. Group workshops were used to guide local health departments through all steps of a project including design and implementation. Each participating local health department constructed a functioning tool to use in the home offices that addressed the participating department’s specific needs. The program did not end when participants returned to the participants’ home offices. The facilitators provided ongoing technical support. The project is a model for how different agencies can collaborate to augment the public health infrastructure in a way that builds capacity and can be adapted to scenarios that are limited by minimal capital input (Miranda, et al., 2005).
Conclusions
Large local jurisdictions are further along in the jurisdictions’ abilities to respond to routine as well as larger-scale incidents than small jurisdictions. In small local jurisdictions, such as Linn County, no allowance for capacity-building resources exists within the fee-for-service and contract model being used by the State of Oregon without supplemental resources being provided or building in additional efficiencies within the system. Because discretionary funds and staff are limited, smaller health departments must free up funds needed to build capacity in essential areas such as foodborne illness investigation and response by increasing efficiency or limiting existing services in other areas.
Recommendations
Building on the lessons learned in the North Carolina GIS project, potential exists to obtain training more efficiently by partnering with a delivery source to provide desired training products or skills that are useable immediately and that are actively supported by the training entity during application or implementation by the agency receiving training. The first application of this training model would be training needed to foster more rapid compliance with Standard 5 of the VNRFRPS. Training can encompass more than a lecture-style format that educates and provides information for use at a later date. Training time can be combined with productive exercises that allow the participant to develop a tool that is ready to use and customized to the participant’s needs. Participants can walk away from the training and workshop with tools for immediate implementation within the participants’ local jurisdictions, enhancing the participants’ capacities to investigate and respond to reports of foodborne illness. In addition, post-training follow-up can keep these tools off the shelf and in-use. Further, this training can be refreshed, improved, and practically applied using annual exercises as outlined in FDA’s VNRFRPS to help small jurisdictions maintain response capabilities.
As an initial step, a small pilot project could be designed to test the North Carolina training model by applying the model to the environmental health role outlined in Standard 5. Ideally, the FDA would work with several small counties in Oregon to provide basic training and follow-up assistance for the development of usable tools or skills needed to accomplish basic compliance with Standard 5. Further, to ensure that systems are used and skills maintained, and to build greater sophistication and sustainability into foodborne illness investigation and response systems, counties (particularly smaller counties) should have opportunities to participate in a table-top exercise at least annually. These annual table-top exercises could be stand-alone events or incorporated into existing conferences.
Acknowledgements
I would like to thank the staff at the International Food Protection Institute (IFPTI), the Subject Matter Experts and mentors, the 2010 Program Fellows, my colleagues in Oregon, the Association of Food and Drug Officials (AFDO), and the regional staff at FDA. I especially want to thank my mentor, Steve Steinhoff; 2010 IFPTI Fellow, Katherine Simon; Dr. Craig Kaml, Director, Curriculum Delivery, IFPTI; Dr. Kieran J. Fogarty, Acting Director of Evaluation, IFPTI; Rick Hallmark; John Kawaguchi; Christie Sweitz; Gerald Barnes; Katey Kennedy; John Marcello; Rick Partipilo; Frank Moore; Tom; and Walker.
Corresponding Author:
Holly Skogley, Linn County Environmental Health Program (Oregon).
Email: hskogley@co.linn.or.us
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