Control of Behavior-Centric Risk Factors Between Two Management Groups

Renita Stroupe

Health Educator

DeKalb County Board of Health

International Food Protection Training Institute (IFPTI)

2017 Fellow in Applied Science, Law, and Policy: Fellowship in Food Protection

Author Note

Renita Stroupe, Health Educator, DeKalb County Board of Health.

This research was conducted as part of the International Food Protection Training Institute’s Fellowship in Food Protection, Cohort VI.

Correspondence concerning this article should be addressed to Renita Stroupe, DeKalb County Board of Health, 445 Winn Way, Decatur, GA 30030;
Email: Renita.Stroupe@dph.ga.gov

Abstract

          Per the Boston Consulting Group, millennials eat out 3.4 times per week, the largest amount in American history. With more people eating out, the significant number of foodborne illness outbreaks associated with consumption from restaurants within the U.S. should be noted. To reduce the frequency of foodborne illness outbreaks associated with these establishments, many states now stipulate that foodservice establishments have some form of an accredited food protection manager. The purpose of this study was to observe the utility of a Certified Food Protection Manager (CFPM) with the implementation of a Food Safety Management system in controlling the occurrence of CDC risk factors within a specific metro-area in Georgia. This study focused on behavior-centric risks; poor personal hygiene/employee health; and protection from contamination/contaminated equipment. Data was collected at 26 establishments to accurately assess the controls in place for each risk factor and determine if there was any relationship between the occurrence of risk factor violations, the presence of a CFPM, and the CFPM implementation of a Food Safety Management System (FSMS). Results indicate that the presence of a CFPM with the implementation of an FSMS reduced the incidence of contaminated equipment and poor personal hygiene/employee health significantly as compared to facilities that do not have a management system. The results also indicate that a CFPM alone has less effect on the reduction of these two risk factors than previously indicated in FDA Retail Food Risk factor study. The study recommends continued educational outreach to food establishment operators using the study results as well as continuing the study’s methodology to analyze after one year those establishments who hired a CFPM and instituted a FSMS.

Control of Behavior-Centric Risk Factors Between Two Management Groups

Background

The Centers for Disease Control and Prevention (CDC) has identified the top five risk factors typically responsible for foodborne illness outbreaks. To observe the occurrence of these risk factors within retail foodservice the Food and Drug Administration (FDA) conducts a risk factor study every ten years. The results of studies have contributed to the development of recommendations and requirements to improve food safety practices in foodservice as well as other areas such as manufacturing. One of the results from these studies has been the recommendation to employ trained and knowledgeable Certified Food Protection Managers (CFPMs) to reduce the incidents of CDC risk factor items.

Another result of these studies has been the adoption of regulations by many states requiring a CFPM. FDA has found the requirement is improving the overall practices within industry. Data from a 2008 study indicate improvement in four categories (excluding proper cooking) when establishments complied with CFPM (FDA, 2009). Research has been utilized to monitor the effects of utilizing a CFPM and the five risk factors identified by the CDC. However, few studies have evaluated how the management system has been formed or created for active managerial control of stated risk factors. The project sought to evaluate if there is a relationship between the lack of CFPM, presence of CFPM, and the implementation of food safety management system in addition to employment of Food Protection Manager on the occurrence of behavior centric risk factor violations; personal health and hygiene and contamination.

Problem Statement

          The degree to which employing a CFPM in comparison to utilizing a food safety management system under the direction of CFPM to reduce incidents of two behavior-centric risk factor violations; poor personal health/hygiene and contaminated equipment/protection from contamination within DeKalb County is unknown.

Research Questions

1.     Does having a CFPM affect risky behavior; specifically, personal health and hygiene and protection from contamination of food and equipment?

2.     Does implementing a management system impact the number of behavior-centric CDC risk factor violations observed in DeKalb County, GA?

3.     Are the CFPMs within DeKalb County implementing a management system that reduces the number of CDC risk factor violations observed?

Methodology

          Methodology in the study mimicked the method utilized by FDA Risk Factor Study 2008 and 2016. A geographical information system (GIS) database containing a listing of businesses throughout the county was used as the establishment inventory for the data collection. Establishments were randomly selected to participate in the study from among all eligible establishments located within boundaries of DeKalb County, Georgia. To further determine the pool of establishments eligible for selection, an assessment was made to exclude operations that handle only pre-packaged food items.

          A sample size of 2% of permitted establishments within DeKalb County, Georgia was selected, however only 1.2% were used due to exclusion criteria (s=26 establishments, n=2209 permitted establishments as of August 30, 2016). In addition to being a permitted facility, establishments must have been in existence for at least 1 year. This time frame was selected to coincide with the requirement for a certified food protection manager within 90 days of permit issuance and to have a record of at least 2 inspections for which violation history can be established. In addition, facilities with limited preparation were excluded. Establishments for which cooking or cooling could not be observed were excluded.

          Each data collection visit was unannounced, to observe the operation in its normal mode. Upon arrival to the establishment, the Environmental Health Specialist (Specialist) explained the purpose of the visit. If entry into the selected establishment was denied by the person in charge, the Specialist did not conduct a data collection. The Specialist then selected a new establishment from the substitute establishment list provided by random number generator for 23 additional facilities. The primary purpose of the data collection was to observe food safety practices and employee behaviors that are associated with the control of foodborne illness risk factors. After discussing the purpose of the data collection, the Specialist conducted a quick walk-though of the establishment’s kitchen. The goal was to identify the critical food preparation processes being conducted at the time of the assessment, so that priorities can be determined. For each critical activity observed during the walk-through, the Specialist determined whether the activity is static (one that will likely be the same over the specified visit) or dynamic (one that will likely be completed soon or will change quickly during the assessment). Based on the walk-through and responses provided by the operator about the specific activities being conducted at the operation specific areas were monitored by the Specialist. The establishment’s menu was reviewed and utilized by the Specialist prior to data collection at the facility as guidance on processes that were to be observed during the assessment.

          The focus of the data collection was observation of two critical foodborne illness risk factors listed on the data collection form; contaminated equipment and personal hygiene. To assess the food safety management system in place the managerial control data collection form utilized in the FDA Retail Food Risk Factor study collected four elements of each establishments management system (FDA, 2009). The management system elements included whether the establishment had procedures, training, and monitoring in place for these risk factors, as well as if a violation was observed during the data collection visit. The operator was asked to provide any documentation utilized for standard procedures, training, or monitoring of employee health and hygiene including handwashing, hygienic practices, exclusion and restriction criteria, and prevention of contamination by hands.

          Determination of CFPM was assessed using the Conference for Food Protection (CFP) accreditation program. Establishments with a person in charge that currently holds an American National Standards Institute-Conference Food Protection (ANSI-CFP) recognized certificate with verifiable proof were recognized, for this study, as having an CFPM employed. Furthermore, if that person was present during the site visit that individual was identified as the person in charge and was expected to convey all necessary information, procedures, documents, as required for the assessment.

Results

          Out of the 26 establishments evaluated, 13 facilities had an FSMS implemented. Three additional facilities were removed from the study because of lack of proof of CFPM employment or failure to employ a CFPM at the establishment during the site visit, see Table 1.

Table 1

Employment of Certified Food Protection Manager (CFPM)

Note. Establishments that could not produce evidence of employment of a CFPM were excluded for this study, the findings at these sites were not included in the data.

Out of the 26 facilities with a CFPM, 13 had documentation of FSMS in place in addition to CFPM. Of these facilities, only 4% had contamination violations compared to 46% facilities with CFPM without a management system and 35% of all establishments (with a CFPM and CFPM with FSMS). Additionally, personal hygiene and health had 4% in facilities that had a CFPM but utilized no food safety management system. All facilities utilizing a FSMS had significantly fewer personal health-hygiene and contamination violations all around, see Table 2 and Figures 1 and 2.

Table 2

Percentage of Risk Factor Violations No CFPM, CFPM, CFPM with Management System

Note. Employee personal health/hygiene risk factor showed statistically significant improvement in establishments utilizing a CFPM with a food safety management system compared to those that employ a CFPM only. Contaminated equipment/protection from contamination showed statistically significant improvement compared to CFPM only.

Figure 1. Observed Violations Between Two Management Groups.

Figure 2. Observed Violations within Management System.

 To assess FSMS, the managerial control data collection form utilized in the FDA Retail Food Risk Factor study was used to collect elements of each establishments management system (FDA, 2009). Not all facilities had a management system that encompassed all elements; procedures, training, and monitoring in place for these risk factors, see Table 3.

Table 3

Components of Food Safety Management System

Note. Food safety management system was assessed for each risk factor; contaminated equipment/protection from contamination and personal health/hygiene. Although, 13 facilities had a food safety management system, majority of establishments were lacking protocols for monitoring these behaviors to assess whether risks were being effectively controlled.

 The person in charge was asked to provide any documentation utilized for standard procedures, training, or monitoring of employee health and hygiene including handwashing, hygienic practices, exclusion and restriction criteria, and prevention of contamination by hands. The person in charge was also asked to provide documentation for standard procedures, training, and monitoring of cleaning and sanitizing food equipment, separation of raw animal foods, and protection from environmental contamination.

          In one case, from inspection history and file review, it was established the facility did have a FSMS, however, the person in charge was not able to produce the written documentation until after the site visit. Monitoring was an element that was lacking in majority of FSMS for both risk factors (Table 3). Only 1 facility had procedures for monitoring protection from contamination controls and 2 establishments had monitoring procedures for personal health and hygiene. Of the 2 establishments that had the personal health/hygiene monitoring protocols, none had observed personal health/hygiene violations. There were not enough facilities with monitoring procedures in place to state statistical significance.

Conclusion

          The results suggest there is a relationship between the CFPM and the CFPM utilizing a written FSMS and incidence of two behavior-centric risk factors; personal health/hygiene and protection from contamination/contaminated equipment.

          Evidence does suggest that a relationship exists between the presence of CFPM and occurrence of employee health/hygiene and protection from contamination risk factor observations. Facilities utilizing a food safety management system; utilizing written procedures, training, and monitoring demonstrated fewer incidents except for employee health. In facilities that had a CFPM and facilities utilizing a Food Safety Management system this risk factor was still observed at least 23% of the time. The data also suggests that the regulation for requiring a food protection manager still leaves a gap in controlling employee behavior. As employee health risk factors were still prevalent approximately one-third of the time. Protection from contamination and preventing contamination of equipment were better controlled by CFPM but the procedures, training and monitoring utilized in FSMS saw fewer incidence of these violations. The integrated strategy of utilizing the CFPM to promote a management system to proactively and continuously prevent, reduce, and eliminate hazards could close this gap.

Recommendations

1.     Food establishments should be encouraged to use a FSMS as the best integrated approach to maintaining the safety and integrity of foods in foodservice establishment.

2.     Agencies should use data, such as in this study in their educational outreach to operators regarding the benefits of a CFPM and a FSMS.

3.     A further study using this methodology should be carried out on an annual basis examining the impact of adopting a CFPM and a FSMS on those food service establishments that currently do not have any preventative control measures or food safety system. The study should also examine food service establishments one year after employing a CFPM and adoption of a FSMS.

Acknowledgements

First, I would like to thank Jennifer Kirby (DeKalb County Board of Health) for assistance with study design and work to better understand the education, and various foodservice establishments within DeKalb County, and for allowing time and access to facilities for this study. I would also like to thank subject matter expert, Dr. Paul Dezendorf, and Charlene Bruce, mentor, for their assistance with their review of the draft. And finally, I would like to thank my fellow Cohort VI members for their encouragement and support throughout the program.

References

Bottlemiller, H. (2012, August 17). Research shows food safety managers have impact. Retrieved from http://www.foodsafetynews.com/2010/10/fda-research-shows-food-safety-managers-have-impact/#.WHMYNFMrLIW

Cates, S. C., Muth, M. K., Karns, S. A., Penne, M. A., Stone, C. N., Harrison, J. E., & Radke, V. J. (2009). Certified kitchen managers: Do they improve restaurant inspection outcomes? Journal of Food Protection, 72(2), 384-391

FDA National Food Retail Team. (2008). Retail food protection foodborne illness risk factor study. Retrieved from http://www.fda.gov/downloads/Food/GuidanceRegulation/RetailFoodProtection/FoodborneIllnessRiskFactorReduction/UCM369245.pdf

Green, L. R., & Selman, C. (2005). Factors impacting food workers’ and managers’ safe food preparation practices: A qualitative study. Food Protection Trends, 25(12), 981-990