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NEHA 2012 AEC – June 2012 1

USING QUALITY IMPROVEMENT TOOLS TO DECREASE CRITICAL RISK FACTOR

VIOLATIONS IN RESTAURANTS

By Paul DeSario, MPH, RS

Cuyahoga County Board of Health

THERE WERE 3 IMPORTANT STEPS TO THIS PROCESS

1. Identify the weaknesses in the program2. Identify what is needed for improvement3. Identify effectiveness of the improvement

IDENTIFYING WEAKNESS

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NEHA 2012 AEC – June 2012 2

EXAMPLE PROJECT: PLAN REVIEW

CQI Tool Used: Flowchart

Upper Left: current processUpper Right: steps to eliminateLower Left: New process

THE ROLE OF ANALYZING DATA USING CUYAHOGA COUNTIES ENTERPRISE SYSTEM FOOD SAFETY SYSTEM

Collected data from 2010 showed a large amount of re-inspections were conducted in 2009 and 2010

Reviewed Enterprise data from the restaurants with the most re-inspections.

A closer look at this data was conducted using Paretos’ logic

ROLE OF ENTERPRISE AND PARETO.

Pareto said that 80% of the work or quantity is conducted by 20% of the people or data

A Pareto chart was created and found that our top 97 facilities out of 4000 have the most violations.

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NEHA 2012 AEC – June 2012 3

RECURRENT VIOLATIONS IDENTIFIED AS THE TARGET

Next step assemble a team and create some ground rules and a timeline because we received a grant from The Ohio Voluntary Accreditation Team.Tom Blackford

Brian Athey

Jim ArmstrongLavonne Lee

WHAT IS NEEDED FOR IMPROVEMENT?

QUALITY IMPROVEMENT TOOLSTEAM CHARTER

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STORYBOARD

Risk factors identified

Conduct Inspection or re-inspection

yes

no

Review inspection with PIC and leave

Immediately corrected ?

yes

no

Using your professional judgment, are their enough factors to increase risk of illness?

no

yes

FISHBONE DIAGRAM

Repeated Violations

Improper training

Disorganized

Habit

Don’t care

Funding/resources

Relationship with Sanitarian

Communication barrier

Interpretation

DECISIONS, DECISIONSAFFINITY DIAGRAM

What motivation will help operators make proper decisions and decrease critical violations?

Positive reinforcement

Create their own plan

educationStaff incentives

Fines

Increased enforcement

Education

Targeted education

Different inspector

Full HACCP Plan

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NEHA 2012 AEC – June 2012 5

WHICH ONE DO WE CHOOSE?PRIORITIZATION MATRICES

Name Positive reinforcement

Create plan

Staff incentives

Fines Increased enforcement

Different inspector

Education Targeted education

Paul 10 100 1 1 1 100 10 100

Tom 1 10 1 1 1 10 10 100

Lavonne 100 10 100 10 10 100 1 10

Brian 1 10 1 100 100 100 1 1

Jim 10 100 1 1 1 10 1 100

Rick 1 100 10 1 10 100 10 100

123 330 114 114 123 420 33 411

RISK CONTROL PLAN

A written plan to reduce Foodborne Illness

1. Identify Critical Risk Factors & Corrective Actions

2. Create Risk Control Plan: Identify controls, Person(s) responsible, Record keeping, Training plan

3. Operator and staff sign-on to Risk Control Plan after review

4. Follow–up to ensure Risk Control Plan is utilized

TARGETED EDUCATION

Review history of their Inspections and create in house training based on their violations.

More in depth than a general In-ServiceGreat response from workers and managers

Future may mix this into the Risk Control PlanWE DID!!

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RAPID CYCLE PROCESS

CREATING THE RAPID CYCLE PROJECT USING A GANTT CHART

Interventions created for measurementHACCP plan

Targeted Education

Risk Control Plan

Incentives

Limitations Time

Complexity

Power

STUDY DESIGN

3 groups pre and post intervention measurement

Rapid Cycle Improvement

Targeted Education Group

Risk Control Plan

Control

Chose top 100 facilities (Pareto Chart)

A single blind study

After the interventions, the re-inspecting sans were not be told which facilities were in the treatment group or control group.

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WHAT WILL THIS DO FOR THE PROGRAM?

If found effective we will change the SOP’s in food to include either or both interventions.

If not?Back to the drawing board and explore those

interventions we ruled out initially

Thomas Edison

“I didn’t fail, I found 10,000

ways not to do it”!

RESULTS FROM RAPID CYCLE IMPROVEMENT STUDY

WHAT DID WE LEARN?

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OVERALL…

Control Group

5% observed violation decrease

Targeted Education Group

33% decrease

Risk Control Plan Group

48% decrease

Hand washing – fewer violations observed in Targeted Ed group

Chemicals – fewer violations observed in RCP group

RAPID CYCLE - RESULTS

Hand Washing

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Control Targeted Education Risk Control Plan

Pre

Post

RAPID CYCLE - RESULTS

Chemicals

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Control Targeted Education Risk Control Plan

Pre

Post

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RAPID CYCLE - RESULTS

Equipment

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Control Targeted Education Risk Control Plan

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RAPID CYCLE - RESULTS

Food

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Control Targeted Education Risk Control Plan

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SIGNIFICANCERisk Control Plan

The 48% decrease was calculated to have a p value of .08

The sample was not large enough to have the power that it needed. To have statistical power, I needed at least 100 facilities per group and not the study size.

Targeted education

The 33% decrease had a p value of .11

Although the statistics were not perfect they were strong enough to make a change to our system and create the enforcement group.

This will be the goal for the enforcement team.

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NEHA 2012 AEC – June 2012 10

LOOKING AT THE DATA

Data showed we needed to make a changeMany re-inspections did not show risk factor

improvementIf we are spending time at the facilities, we need to

show that that time was useful not wastedWe were operating under the definition of

“insanity”THIS HAS TO CHANGE

HOW DO WE CAPITALIZE ON THESE RESULTS?

SOP’s for the Targeted Education Plan and Risk Control Plan

TARGETED EDUCATION: STANDARD OPERATING PROCEDURE

Conduct file review – assess Critical Risk Factor’s (CRF)

Utilize Targeted Ed documentTailor info according to CRF’s observed

Address critical violations with staff and management

Kitchen walk-through showing what/how to correct the risky practices

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RISK CONTROL PLAN: SOP

Conduct file review – assess CRF’s Fill out CRF Identified with PIC

Observation, Uncontrolled Process, Hazard, Critical Limits, Corrective Action

Risk Control SectionWhat needs controlled, how controlled, who is

responsible, records, and trainingPIC signs. Staff is to sign by follow-up dateCorrections made and RCP to be followed or bring in for a

hearing

CONCLUSIONWhat did this teach us?

THE CQI PROCESS:THIS IS HOW WE APPLIED CQI PRINCIPLES TO THE FOOD PROGRAM

Establish a FrameworkWhat do we want to do?

What do we want changed?

What is the current process?

How do we want to do it instead?

How much do we want to change?

Will there be data to support the change?

Does this change have any relevancy to agency goals?

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NEHA 2012 AEC – June 2012 12

WHAT’S NEXT IN THE CONTINUOUS QUALITY PLANNING PROCESS:

What will be measured?

Violations per restaurant

Violations per type of restaurantViolation number by sanitarian

Violation type by sanitarian

Facilities with food safety trainingType of training in facilities

DEMMING STATED

,

“It is not necessary to change, survival is not mandatory”