Southern Nevada Health District
Instilling Food Safety Culture Prior to Permit Issuance
The Southern Nevada Health District (SNHD) services the municipalities of Clark County, Henderson, City of Las Vegas, North Las Vegas, Mesquite, and Boulder City, Nevada. The combined resident population for these municipalities is 2.1 million. Additionally, each year the region hosts 40 million visitors. Over 19,000 food establishments are currently permitted, and an average of 250 permits are released each month by the Facilities Design Assessment and Permitting (FDAP) office. The Revised Permitting Process (RPP) protects residents, visitors and the region's tourism industry by promoting food safety culture in newly permitted facilities.
Prior to 2014, the permitting process required that food facility applicants submit construction plans with supporting documentation of their operating procedures at an initial intake meeting with our Facilities Design Assessment and Permitting (FDAP) staff. Once the plans were approved, field inspections were conducted at several points during construction, and the permit was released following a final permitting inspection. Following release of the permit, the facility could begin operation. Approximately 30-60 days following start of operation, an initial grading inspection was performed by the assigned Food Operations Inspector to evaluate food safety practices.
With this process in place, 6.4% of newly permitted facilities were found to have an adverse outcome (downgrade or closure) at the initial grading inspection. This was understood to result from observations that many new operators lacked the requisite food safety knowledge and/or restaurant experience to adequately control foodborne illness risk factors. Because these operators were potentially putting the public at risk prior to their first graded inspection, the FDAP office revised the permitting process to introduce and reinforce food safety culture concepts prior to issuance of health permits. The goal of the Revised Permitting Process (RPP) was to reduce the downgrade/closure rate at initial grading inspections for newly permitted facilities to 5% or less. Additionally, it was hoped that introduction to and reinforcement of food safety concepts throughout the permitting process would produce sustainable practices to improve overall food safety performance during future operation.
The RPP consists of three components: 1) incorporation of food safety knowledge assessment at the initial plans intake meeting 2) required Food Safety Assessment Meeting (FSAM) for applicants needing assistance in developing food safety knowledge and practices, and 3) a collaborative final permitting inspection including the assigned operations inspector, to further emphasize food safety concepts.
Implementation of the RPP was staged, and began with the introduction of the collaborative final inspection concept. Operations inspectors were required to attend all final permitting inspections with FDAP staff to initiate the relationship between the permittee and the inspector, reinforce the need for active managerial control, and familiarize the inspector with the establishment. All staff required training on what their roles would be during the final permitting inspection, how to handle scheduling conflicts, and a revised coding scheme for the inspection software.
During this period, standardized practices were developed and implemented for FDAP staff. These included identification and evaluation of minimum sanitary design standards, revision of the intake questionnaire to include operational concerns, and mandatory attendance of someone knowledgeable about food operations at the initial plans intake meeting. FDAP staff were trained to incorporate menu review and operational considerations into the equipment and construction review, and to determine if the applicant demonstrated sufficient managerial control over foodborne illness risk factors.
Finally, the Food Safety Assessment Meeting (FSAM) parameters and procedures were developed. The FSAM is a mandatory meeting between the permit applicant, the FDAP inspector and the Food Operations inspector wherein the applicant must demonstrate sufficient food safety knowledge to operate their establishment in a manner that protects public health. Development of the FSAM included establishment of criteria for requiring an FSAM, development of discussion guidelines for the FSAM based on the FDA's Foodborne Illness Risk Factors, description of Food Operations and FDAP roles during the FSAM, and actual training of EHS staff to conduct FSAMs.
The RPP was fully implemented by October 2014, with ongoing improvements based on feedback from inspectors and operators. Data collected to this point shows that the RPP met its goal by reducing the initial downgrade/closure rate for new facilities' initial inspections to 3.3%. As this was a pilot program and a novel concept, implementing it across the entire SNHD EH staff took a large amount of effort from staff and supervision. Implementation success was largely due to support from upper management, and the previous introduction of the Foodborne Illness Risk Factor concept to operators during routine inspections.
Approximately 6% of newly permitted food facilities were placing the public at risk by operating without adequate food safety knowledge/active managerial control over risk factors. This was evidenced by the number of downgrades and closures occurring at the initial grading inspection following permit approval.
Approximately 250 new food establishment permits are released each month. 2.1 million residents and over 40 million visitors to Clark County who consume or purchase food products at newly permitted food establishments were potentially affected by this issue.
No prior efforts were made that specifically targeted safe operation of newly permitted facilities, outside of routine inspections which took place 30 to 60 days following issuance of the permit. SNHD initiated a Think Riskâ€ program in 2010 to reinforce active managerial control over foodborne illness risk factors, but this had no impact on downgrade/closure rates for new facilities, since Think Riskâ€ concepts were not introduced until the facility was actually inspected.
The Revised Permitting Process (RPP) introduces food safety culture when the health permit is first applied for. EHS staff evaluate the applicants' level of food safety knowledge during the initial meeting, thereby reinforcing the importance of developing managerial controls and staff training programs before opening the restaurant. Utilization of the Food Safety Assessment Meeting (FSAM) allows the applicant to further prepare for safe operation by mandating understanding of food safety concepts, analyzing their workflow, and development of employee training programs. The applicant must actively demonstrate control over risk factors in their facility in order to passâ€ the FSAM and proceed with the permitting process. Finally, the RPP allows SNHD staff to slow down or stop the permitting process until the applicant is able to demonstrate that they can operate safely. The initial downgrade/closure rate for newly permitted facilities has been cut in half since implementation.
The RPP incorporated changes into existing workflows as well as introduction of a novel concept. Plan review meeting content was revised to include evaluation of the applicants' food safety knowledge (including a food safety quiz which is completed prior to the meeting) and detailed discussions about operations, in addition to construction and design evaluation. The FSAM is a novel concept which, as far as we know, is only practiced at SNHD. We developed and implemented the program using the Plan-Do-Study-Act model, and continue to use PDSA to refine the process.
The project was initiated in May 2014 when EH Management mandated collaborative final permitting inspections including both the FDAP inspector and the assigned Food Operations inspector. At that time, the issue of releasing permits to applicants who did not have requisite food safety knowledge was addressed, and staff from FDAP and Food Operations were instructed to collaborate on a solution. The concept of the Food Safety Assessment Meeting was developed in response to analysis of the problem. Additionally, it was determined that FDAP staff would require training to incorporate evaluation of food safety knowledge into the existing plan review process. The project was anticipated to be completed within 12 months.
Throughout the development and implementation process, project staff worked closely with SNHD's EH Analyst and IT department to develop reports and coding to support data analysis and collection. Project staff also regularly consulted the Food Operations supervisory unit to develop implementation schedules and plans. Inspection staff themselves were trained on the new processes, and consulted throughout for feedback on methods. New documents had to be developed for use by inspectors and permit applicants both to support the evaluation of food safety knowledge and to collect pertinent data.
The project itself was presented to multiple outside individuals and entities both to make them aware of the project and to get feedback, including an NSF trainer, the Nevada Food Safety Task Force, and the Nevada Restaurant Association. Additionally, permit applicants experiencing the new procedures were advised they were participating in a pilot program and interviewed for feedback. This was especially important during development of the FSAM, as we would frequently have up to five Food Operations inspectors observing the meetings as part of the training process. By March 2015, all training was considered completed and the process was considered finalizedâ€. We are now in the data collection and evaluation phase.
This project did not require any special funding or budgeting. We are currently evaluating the cost-effectiveness of the FSAM, as it is arguably the most time-intensive aspect of the program.
The goal of the RPP was to reduce the number of downgrades and closures at the initial grading inspection for newly permitted facilities to 5%. This goal was based on an original data set that showed that at least 9% of newly permitted facilities were operating with unsafe practices, based on downgrade/closure rates, and we wanted to cut that rate in half. We found out that our original reports had errors, which had artificially inflated the downgrade/closure rates. Once we repaired the data, we found that only 6% of newly permitted facilities were experiencing downgrade/closures at the initial grading inspection. Nevertheless, implementation of the new process reduced that rate by about half, so we were still able to achieve our original objective.
All data was collected and analyzed in-house, using our Envision Connect software to collect data and generate reports. A critical component of the program was proper development of coding schemes to enable capturing essential data. This included separate codes for use by FDAP staff and Food Operations inspectors during collaborative final inspections and FSAMs, to prevent duplication of statistics. For instance, because both the FDAP inspector and the Food Operations inspector participate in the FSAM, and both have to enter that activity in the computer system to log their time, we needed a way to extract that only one FSAM was performed.
Reports developed for this project included downgrade/closure rates for the first grading inspection following the release of the permit and downgrade/closure rates for facilities that participated in an FSAM. These were compared to overall downgrade/closure rates and rates prior to implementation of the project.
While we have not adjusted the process yet due to data collected, we did make adjustments throughout implementation based on feedback received from EH staff and permit applicants. Some of the changes included revisions to questionnaires utilized by the permit applicants, and guidance documents used by staff.
Because this practice is only dependent upon staff availability, we do not anticipate sustainability issues in the immediate future. FDAP staff initially faced the common obstacle of not having the right representatives available during the initial plan review meeting. Contactors, architects and plans expediters were accustomed to showing up alone and just reviewing the plans with the FDAP inspector. The new process required that someone knowledgeable about the food operation be present during the meeting as well, and this took some time for everyone to get used to. One positive result is that there is now a community-wide expectation that the food safety evaluation will occur, and operators are arriving much better prepared than before the RPP was implemented. Our FSAM rate has actually dropped simply because applicants come to the plan review meeting with operational plans supporting safe food handling practices already in place. Because we have had no pushback from the community, our Board of Health, or other sources, we believe there is adequate stakeholder commitment to sustain the practice. We will be conducting a cost/benefit analysis with regard to the FSAM portion since this is the most time-intensive component of the process for staff.