Retail Food Establishment Virtual Training Inspections Protocol Efficacy within Fairfax Health District in Virginia
Sion Smith
Environmental Health Specialist, Fairfax County Health Department, VA
Abstract
COVID-19 changed retail food establishment inspections in 2020. Virginia Governor Ralph Northam issued multiple Executive Orders (EO) to contain the spread of the virus, and the Virginia Department of Health (VDH) suspended routine regulatory inspections of retail food establishments and approved a provision for virtual inspections. Virtual inspections were not conducted in Virginia retail food establishments prior to the pandemic. The focus of this study was to develop a method for evaluating virtual inspections used in Fairfax Health District to assess food safety practices during the COVID-19 pandemic. Survey data completed by Northern Virginia Health Districts and actual program data from the Fairfax Health District were used to evaluate the effectiveness of virtual inspections and lessons learned while conducting virtual inspections. Results show that virtual inspections may be an effective tool in performing routine inspections, but there were limitations. Process improvements, additional research, and defining the scope of virtual inspections after the pandemic are recommended.
Key words: virtual inspection, risk factor assessment, COVID-19 inspection protocols, continuous process improvement
Retail Food Establishment Virtual Training Inspections Protocol Efficacy in
Fairfax County, Virginia
Background
COVID-19 changed retail food establishment inspections in 2020. The pandemic resulted in 32,228,003 cases of COVID-19 and 574,220 deaths in the United States as of May 4, 2021 according to the Centers for Disease Control and Prevention (COVID Data Tracker, 2021). Virginia had 662,696 COVID cases and 10,823 COVID-related deaths (COVID-19 in Virginia, 2021). Also, as of May 4, 2021, 77,019 COVID cases and 1,102 COVID-related deaths have occurred within Fairfax Health District in Virginia. (COVID-19 Case Data for Fairfax Health District, 2021).
Virginia Governor Ralph Northam declared a State of Emergency March 12, 2020 and issued multiple Executive Orders (EO) to contain the spread of the virus and mitigate its impact within Virginia. The Virginia Department of Health (VDH), which administers Chapter 421 Food Regulations - Code of Virginia, suspended routine regulatory inspections of retail food establishments and approved a provision for virtual training inspections by the 35 Health Districts within Virginia. Virtual inspections are called virtual training inspections in Virginia because of the limitations posed by conducting food safety inspections in a virtual environment. Some inspection items, such as proper disposition of food, are difficult to observe remotely. Calling these virtual training inspections acknowledges the limitation and differentiates this method from a standard routine inspection.
Code of Virginia § 35.1-22. Periodic inspections mandates one routine retail food establishment to be inspected at least annually, with no more than 12 months elapsing between each such inspection (Code of Virginia, 2020). This requirement was met with an onsite routine inspection in Virginia prior to COVID-19. After the VDH moratorium on onsite routine inspections, the objective of monitoring and educating retail food establishments’ food safety practices was met using the virtual training inspection protocol developed by VDH within each of the Health Districts beginning March 2020. Various iterations of the virtual training inspections were used to assess key considerations for how foods offered at retail can be safely handled and delivered to the public while mirroring social distancing and gathering restrictions stipulated in Executive Orders. Early virtual training inspections were performed, via telephone, by food standardized Environmental Health Specialists (EHSs).
VDH released the Enhanced Virtual Training Inspection (EVTI) protocol in August 2020. Inspections were completed using guidance provided in the Enhanced Food Safety Assessment Tool document to assess risk factors associated with foodborne illness; much like standard risk factor assessments performed onsite. The EVTI protocol was used to perform virtual inspections. The tool provides guidance on assessing risk factors in a virtual environment. This new protocol also added a visual component to the inspection process by requiring video calls instead of phone calls to connect with the Person-in-Charge (PIC).
The EVTI protocol was implemented in Fairfax Health District in October 2020. Fairfax Health District serves residents of Fairfax County, Virginia and associated cities of Fairfax and Falls Church and towns of Clifton, Herndon, and Vienna. Fairfax Health District is located about 10 miles outside Washington, D.C. with a population of approximately 1.2 million residents living within a 406 square mile area. Fairfax County Health Department’s Environmental Health Division licensed and regulated approximately 3,600 retail food establishments in 2019, resulting in approximately 9,000 inspections completed by 20 full-time food standardized EHSs and eight part-time EHSs. Approximately the same number of retail food establishments were operating in 2020, but virtual training inspections were completed by five full-time food standardized EHSs and one part-time EHS due to staff deployment to COVID response.
Virtual inspections were not conducted in Virginia retail food establishments prior to the pandemic. No data was available that measured virtual inspection efficacy, nor was data available that measured virtual training inspection protocol efficacy. The focus of this study was to develop a method for evaluating the EVTI protocol used in Fairfax Health District to assess food safety practices during the COVID-19 pandemic. In addition, lessons learned among Northern Virginia Health Districts, while implementing EVTIs, were evaluated to inform continuous process improvement for this method of conducting inspections.
Problem Statement
No descriptive or quantitative data exist regarding efficacy of the EVTI protocol used in assessing retail food establishments within Fairfax Health District in Virginia.
Research Questions
What metrics would be helpful in determining the effectiveness of the enhanced virtual training inspection protocol?
What do preliminary compliance data show regarding effectiveness of the enhanced virtual training inspection protocol?
What lessons were learned from conducting enhanced virtual training inspections during a public health emergency?
Methodology
An electronic survey consisting of 10 questions assessing the EVTI protocol and seeking lessons learned was developed in SurveyMonkey. The survey was distributed, via email, to environmental health managers overseeing food safety within Northern Virginia Health Districts. The five Health Districts within Northern Virginia are Alexandria, Arlington, Fairfax, Loudoun, and Prince William. These Health Districts were selected for analysis because they conducted enhanced virtual training inspections in 2020 and have similar demographics. The survey was distributed December 1, 2020 and responses were collected until January 14, 2021.
Survey data collected from Northern Virginia Health Districts and actual performance data from Fairfax Health District were used to evaluate the efficacy of the EVTI protocol compared to a standard onsite routine inspection visit. Three areas consistently examined when evaluating efficacy of a food safety inspection program in Virginia include:
1. Was the inspection completed?
2. Was the inspection completed on time?
3. Were the risk factors consistently assessed?
Survey data collected from Northern Virginia Health Districts and compliance data collected in Fairfax Health District using the EVTI protocol was analyzed to complete a preliminary analysis regarding effectiveness of EVTIs in relation to the risk factors that were assessed. Inspection data was extracted from the internal Planning and Land Use System (PLUS) database for November 2020 and compared to a baseline developed from the Risk Factor Study completed in 2016 to meet Voluntary National Retail Food Regulatory Program Standards, Standard 9 requirements (Voluntary National Retail Food Regulatory Retail Standards - November 2019, 2020).
Results
Fairfax Health District’s 2019 inspection performance data was examined to determine whether EVTIs yield similar performance outcomes to onsite inspections. The expected outcome was all inspections completed on-time. In 2019, 100% of the inspections were completed within the prescribed time. In 2020, 100% of the EVTIs were completed on time, but there is no official inspection performance data available for comparison because onsite inspections were conducted during the first quarter and inspections then transitioned to virtual training inspections due to COVID-19. Therefore, responses from Northern Virginia Health Districts to two survey questions assessing whether EVTIs could be used to complete a routine inspection on time were used as a proxy measure. One question assessed the average time to contact a Person-in-Charge (PIC) to schedule an inspection. Survey responses were received from eight EHSs at Arlington, Fairfax, and Loudoun Health Districts. Seventy-five percent of survey respondents indicated they were able to make contact within three days. Another question assessed average time to complete an EVTI. Eight-seven percent of the respondents indicated they were able to complete the inspection within two hours. The pandemic impacted the response rate due to staff being deployed to various aspects of COVID-19 response across the Health Districts.
Compliance data collected from EVTIs conducted in Fairfax Health District in November 2020 were analyzed to complete a preliminary analysis regarding effectiveness of EVTIs. Among the 108 inspections completed in November 2020, compliance with proper cook temperature requirements was comparable to the baseline risk factor data for Fairfax Health District at 100% compliance. Decreases in compliance with safe food source (2.5%), proper holding (3.9%), clean equipment/cross-contamination prevention (2.9%), and good personal hygiene (5.9%) requirements were observed among the 108 retail food establishments inspected in November 2020 compared to the baseline constructed from the 2016 Risk Factor Study (Figure 1).
Figure 1
Risk Factor Analysis
Northern Virginia Health Districts were surveyed to determine whether EVTIs were an effective tool for assessing foodborne illness risk factors. The majority of the respondents found good hygienic practices (62.5%) and clean equipment/cross-contamination prevention (50.0%) somewhat difficult to assess using EVTIs. Approved food source (87.5%), adequate cook temperature (75.0%), and proper holding (75.0%) were easy to assess using EVTIs according to the respondents. Northern Virginia Health Districts shared the following insights about what worked well and what could be improved with EVTIs (Table 1):
Table 1
Lessons Learned from Northern Virginia Health Districts
Conclusions
Study results indicate inspections may be completed on time via virtual delivery, but there may be some process improvements needed to ensure all inspections can be completed on time. Two respondents took close to a week to make contact with a PIC to schedule an inspection and one respondent had to make multiple calls to complete an inspection. Although there were challenges with the lead time needed to make contact with a PIC and connectivity during an inspection, EHSs in the Fairfax Health District were able to conduct 7,813 inspections in 2020 with five full-time staff and one part-time staff conducting inspections. For comparison, 9,048 inspections were completed by 20 full-time and eight part-time EHSs in 2019. Staffing ratios at the other Health Districts are unknown, but 75% of the respondents were able to conduct the virtual inspections within two hours.
Preliminary compliance data and survey responses show that EVTIs are capable of capturing food safety violations. A slight decrease in compliance was observed using EVTIs, compared to the baseline, but there may be confounding factors associated with the pandemic that affected food safety performance among this cohort of retail food establishments. Food establishments had to navigate operating a business with limited staff, new health and safety mandates, and other challenges during uncertain economic times. Those factors could have had an impact on inspection performance. Another reason for the observed decrease in compliance could be that violations that do occur are more readily observable during virtual inspections. Additional research would be needed to test that hypothesis.
Recommendations
The following recommendations are offered to inform continuous process improvements for virtual inspections:
1. Keep contact information for retail food establishments updated and use a checklist that describes what to expect during a virtual inspection and what tools to have available during the call (e.g., food thermometer, sanitizer test strip). Schedule virtual inspections and ask for applicable documentation (e.g., employee health, parasite destruction) ahead of time in order to complete the inspection within two hours.
2. Conduct additional research with this cohort of retail food establishments to determine if there is a difference in compliance when conducting EVTIs versus standard on-site routine inspections. Analysis of compliance data prior to the pandemic, during the pandemic, and after the pandemic would be informative in determining efficacy of virtual inspections in maintaining long-term compliance with food safety requirements.
3. Consider routinely using EVTIs in retail food establishments that practice active managerial control, and when completing follow-up visits post-pandemic. Virtual inspection of retail food establishments that have a history of good performance and the limited scope of conducting virtual follow-up visits may address the concerns about the limitations posed by virtual inspections.
Acknowledgments
This project would not have been possible without support from my mentor Brian Collins and the Fairfax County Health Department Environmental Health program leadership Pieter Sheehan, Adrian Joye, and John Yetman. Much gratitude is due to Ryan Mesch and my colleagues at Loudoun, Arlington, and Fairfax Health Districts for providing insights about the virtual training inspection process. I thank Suja Warrier and Kevin Crisler for providing me with program data and Shannon McKeon and Taylor Fletcher for giving me time away from the COVID-19 response to participate in this fellowship. I thank Joe Corby for helping me get this project off the ground, and Kathy Fedder, Doug Saunders, Gerald Wojtala, and Craig Kaml for their feedback throughout the process. Lastly, I would like to thank David Lawrence for introducing me to International Food Protection Training Institute (IFPTI) and everyone at IFPTI for giving me the opportunity to be a part of Cohort IX. It was a tremendous growth opportunity and an unforgettable journey with Cohort IX fellows.
References
Centers for Disease Control and Prevention (2021). COVID data tracker. https://covid.cdc.gov/covid-data-tracker/#datatracker-home
COVID-19 case data for Fairfax health district. (2021) Fairfax County, Virginia. https://www.fairfaxcounty.gov/covid19/case-information
U.S. Food and Drug Administration (2019). Voluntary national retail food regulatory retail standards. https://www.fda.gov/food/voluntary-national-retail-food-regulatory-program-standards/voluntary-national-retail-food-regulatory-program-standards-november-2019
Virginia Department of Health. (2021). COVID-19 in Virginia (2021). https://www.vdh.virginia.gov/coronavirus/covid-19-in-virginia/
Code of Virginia, Title 35.1 Hotels, Restaurants, Summer Camps, and Campgrounds, § 35.1-22. (2017).
Author Note
Sion Smith, Environmental Health Specialist
Fairfax County Health Department
This research was conducted as part of the International Food Protection Training Institute’s Fellowship in Food Protection, Cohort IX
Correspondence concerning this article should be addressed to:
Sion Smith, Fairfax County Health Department
10777 Main Street, Suite 111, Fairfax, Virginia 22030
Sion.Smith@fairfaxcounty.gov
*Funding for this statement, publication, press release, etc., was made possible, in part, by the Food and Drug Administration through grant 5U18FD005964 and the Association of Food and Drug Officials. Views expressed in written materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services; nor does any mention of trade names, commercial practices, or organization imply endorsement by the United States Government.