Make Food Safer with Employee Health Achievers

State: GA Type: Promising Practice Year: 2020

The Cobb & Douglas Public Health (CDPH) health district is a diverse community located northwest of Atlanta, Georgia.  Based on 2018 statistics from the US Census Bureau, Cobb County has a population of about 756,865 people of which 62.6% are white, 28.7% Black or African American, 13.2% Hispanic, 5.6% Asian, and 1% other ethnicities.  Douglas County has a smaller population of about 145,331 people of which 46.7% are white, 48,4% Black or African American, 10% Hispanic, 1.7 % Asian and 1% other ethnicities.  

CDPH's Center for Environmental Health regulates over 2400 food service facilities with the goal of minimizing the potential for foodborne outbreaks.  Over the past five years, our health district has had a number of foodborne illness outbreaks in which employee health & hygiene was found to be a major contributing factor during foodborne illness investigations and the analysis of our Risk Factor Study results.   In addition, it has been recognized that the comprehensive employee health requirements of our state's Rules and Regulations for Food Service --which are based on the FDA Model Food Code-- can seem overwhelming to not only food service operators but our inspection staff as well.   The Center for Environmental is working to help ensure that food service operators have the proper understanding to achieve an effective and operational Employee Health Policy that is being properly assessed by our staff. Having and understanding an effective Employee Health Policy is a critical component for minimizing the occurrence of diseases spread through food in food service establishments.  The Employee Health Achievers project serves to enhance employee health practices and understanding beyond regulatory requirements and strengthens our partnership with the food service industry and community as well as improve upon inspector assessment of compliance. 

About 280 randomly selected food service facilities were assessed using a risk factor evaluation tool provided by the U. S. Food and Drug Administration (FDA) to identify foodborne illness risk factors and public health interventions needing improvement.  In regard to 6 out of 7 Employee Health elements assessed during the FDA risk factor study, at least one-third of the facilities assessed within our health district were out of compliance with employee health.  Thus, this project uses the empowerment theory to enhance employee health awareness and compliance via the intervention strategies of this campaign which are presented below.

The vast majority of our facilities receive a copy of the Employee Health RED Book, which was authored by the Georgia Department of Public Health's Environmental Health Section.  This book was based upon guidance provided by the FDA, with a small modification made locally by permission.  The food inspectors distribute the books during routine inspection visits and review the 5 main areas of an employee health policy with the operator. Operators demonstrating a compliant and fully operational employee health policy become eligible to take a voluntary online quiz on Employee Health.  Those operators achieving a score of 100% on the quiz receive an attractive, easily identifiable certificate of recognition to post in their facilities and their establishments' names and locations are, in turn, posted on our district's website as Employee Health Achievers

After implementing these strategies from the fall of 2018 through mid-2020, it is believed that employee health compliance in the district will improve by at least 25%.  The posting of the facility name on the website serves as an incentive for participation and compliance.

How does an establishment earn the recognition of being an Employee Health Achiever?  Per our website, the person-in-charge of the establishment must:

  • show proof of providing-- and the facility's food workers acknowledging--an Employee Health Agreement;
  • include the 5 required parts in the facility's Employee Health Policy [signs and symptoms of disease; the 6 diseases reportable to the health authority; when to restrict food workers; when to exclude food workers; and when workers may return to work]; and
  • pass an Employee Health & Hygiene quiz made available on the CDPH website

Tools made available to help operators with their employee health policy development and to help prepare for the Employee Health & Hygiene quiz are as follows:

Employee Health RED Book [also available in Spanish and Simplified Chinese]

FDA Employee Health and Personal Hygiene Handbook

STOP Employee Health Alert Placard

After recognizing that food service operators were having difficulty understanding and communicating to their staff  the employee health requirements of Georgia's Food Service Rules and Regulations/FDA Food Code recommendations and that the lack of employee health & hygiene compliance was a contributing factor in local foodborne outbreaks, the need for an effective intervention strategy became obvious to our department.  This pressing need led to the development of the Employee Health Achievers campaign.   

The Georgia Department of Public Health had already provided online access to their Employee Health RED Book, which helped summarize their Employee Health requirements via colorful flow charts and definitions.  After local review of this document, the CDPH Center for Environmental Health asked for permission to make a modification to the document to improve its accuracy [in English and Spanish] and be allowed to provide durable hard copies for easy use by our food service operators.   Permission was granted and funds received from an Association of Food and Drug Officials (AFDO) grant was used to produce 2800 hard copies [2300 in English and 500 in Spanish].   Funding from AFDO is often made available to health districts such as CDPH that are striving to meet the FDA's Voluntary National Retail Food Regulatory Program Standards via competitive small projects grants.  More books were able to be produced for the cost through the use of a state operated non-profit vendor.  The grant also helped to fund the cost of the certificates of recognition that were printed to recognize those scoring 100% on the online quiz.  The quiz itself and the stats for monitoring were provided via a Survey Monkey account which CDPH already had in existence.  Such an account can be obtained by any health district for free to a nominal fee depending on the kind of features included in the account.  The public recognition link on the CDPH website is updated on a monthly basis and serves as an incentive for operator participation.  

The program has been introduced to more than 3/5's of our district's food service facility operators.  Many of these facilities are a part of chain operations that not only have establishments in Cobb and Douglas counties but throughout the state.  As employee health compliance has improved within our local district, many area operators have, in turn, shared that same information with their facilities in districts in other parts of the state, thus, improving compliance beyond our jurisdictional boundaries. Although the completion of the Employee Health quiz is not mandatory by regulation, over 700 individual attempts at the quiz have been recorded via Survey Monkey.  If a score of 100% is not achieved, the candidate is notified of the questions missed so that the correct answer may be obtained by researching the resources provided on the CDPH website which not only prepares the candidate to re-take the quiz but better familiarizes the candidate with how to use the resources should the scenario occur in reality.  

One month after announcing the launch of the EHA program, more than 100 persons had met the requirements for Employee Health Achiever recognition.  Not only did they receive attractive, recognizable certificates to post but their achievements are announced periodically via CDPH Food Safety blog posts and emails via our food service facility data base. To encourage continued Employee Health compliance once a facility's name has been added to the website, the terms and conditions related to the posting were updated.  If it has been found upon two consecutive routine inspections that a listed facility has not been found in compliance with Employee Health requirements, the facility's name will be removed from the website.  Over 200 facilities have been added to the website thus far, and as of this date, no posted facility has been marked in non-compliance more than once. 

A theme that has been consistent throughout our department in regard to Food Safety is that We're all in this together.”  That spirit is the piece of the puzzle that has made the Employee Health Achievers campaign such a success.  The desire for the district's Food Safety program to go to another level required the dedication and support of staff in various facets of CDPH including not only Environmental Health, Administration, Epidemiology and the Health Director's office.  The health district is voluntarily enrolled in the FDA Voluntary National Retail Food Regulatory Program Standards.  In order to meet the requirements of Program Standard 9, the district conducted a Risk Factor Study of our food service establishments.  Along with assessing specific risk factors for foodborne illness specified by the FDA, the following Employee Health related elements were also specified by the FDA for assessment:

1. Food employees exhibiting certain illness symptoms or conditions that require exclusion or restriction in the Food Code, ARE OBSERVED within the establishment during the data collection.

2. Are food employees and conditional employees informed of their responsibility to report to the person-in-charge illness SYMPTOMS as specified in Section 2201.11 of the Food Code?

 3. Are food employees and conditional employees informed of their responsibility to report to the person-in-charge diagnosis with, or exposure to, the specific ILLNESSES specified in Section 2-201.11 of the Food Code?

4. Is management aware of its responsibility to NOTIFY THE REGULATORY AUTHORITY when a food employee is jaundiced or diagnosed with an illness due to a pathogen specified in Section 2-201.11 of the Food Code?

5. Is the management & employee health policy consistent with 2-201.12 of the Food Code for EXCLUDING AND RESTRICTING food employees and conditional employees on the basis of their health and activities as they relate to diseases that are transmitted through foods?

6. Is the management & employee health policy consistent with 2-201.13 of the Food Code for REMOVAL OF EXCLUSIONS AND RESTRICTIONS of food employees and conditional employees on the basis of their health and activities as they relate to diseases that are transmitted through foods?

7. Management has a copy of FDA Employee Health and Personal Hygiene Handbook OR cd database?

The results of the study were entered into a web-based system called FoodSHIELDFoodSHIELD is a shared system by the nation's public health and food regulatory officials for communication, coordination, education, and training in the food and agriculture sectors. This secure system allows the local, state, and federal levels across the nation to work together.  Experience as to what does and doesn't work well regarding various areas of food safety can be shared through the site and analysis of the data entered showed that over one-third of the facilities [which were randomly selected via a statistical program provided by FDA] were not in compliance with 6 out of the 7 elements listed above.  Hence, the Employee Health Achievers (EHA) program evolved as an intervention strategy to improve compliance and reduce the possibility of non-compliance with Employee Health requirements being a contributor to cases of foodborne illness in the district.

Marketing of the EHA program involved persons in various parts of our community, industry and regulatory network.  The program was introduced to local food service operators via:  (1) emails that were sent to food service facilities within the health district;  (2) district Environmental Health Specialists during routine field visits; (3) the CDPH Food Safety blog; (4) an email from our industry partners at the Georgia Restaurant Association;  (5) in-person presentations to the Nutrition Services Department staff of the local school districts; and (6) the CDPH Food Safety Partnership Panel video presentation entitled The Risk Factor Challenge.  The program has, also, been presented to (7) the Georgia public health districts via the 2018 District Food Standards Conference and (8) during the Fall 2019 meeting of the Georgia Food Safety Task Force.  These elements will be highlighted below.

(1) Emails that were sent to food service facilities within the health district--  An email that summarized the results of the Risk Factor Study and the commencement of the Employee Health Achievers recognition program was sent out in September 2018 to district food service facilities which included a link to the Food Safety Partnership panel video on the topic and links to the STOP Alert placards, Employee Health RED Books link, link to Food Safety blog post regarding the campaign, and the online Employee Health Achievers quiz link.  Additional emails (along with an EHA overview that was mailed with our annual service fee invoices) were sent out to provide status updates and EHA program availability information.

(2) District Environmental Health Specialists during routine field visits—Using the district designed STOP Alert placards, the Environmental Health Specialists, during routine inspections, walked the persons-in-charge through a review of the five necessary components of a compliant Employee Health policy (which are noted on the back side of the placard), and introduced them to the online tools that would prepare them to take the Employee Health Achievers quiz. A hard copy of the Employee Health RED Book was also issued to operators that did not already have the book or the online link.  Depending on the predominant language spoken at the facility, a copy in Spanish was made available or a link to the CDPH website provided to access the information in other languages.

(3) The CDPH Food Safety blog—For approximately five years, the CDPH Center for Environmental Health has provided a Food Safety blog that has over 1000 followers.  A post introducing the Employee Health Achievers campaign was made at its commencement and periodically posts have been used to highlight the EHA campaign's progress and to introduce it to new managers and followers of the blog.  Since the blog is accessed by not only food service operators but by consumers and regulatory officials as well, it has served as a good way to keep each group informed.

(4) Presentations to the Nutrition Services Department staff of the local school districts—A presentation was given to the Cobb County Schools Nutrition Services staff and to the Marietta City Schools Nutrition Services staff.  The Cobb County Schools system is one of the largest school systems in the state of Georgia and the majority of their schools have been listed on our website as having achieved the designation of Employee Health Achievers. The EHA program has been highly supported by the leadership of the Cobb County Schools Nutrition Services department.

(5) An email from our industry partners at the Georgia Restaurant Association-- After receiving a presentation on the EHA campaign, the Georgia Restaurant Association sent out a blast email to its members as well as other food service facility owners (which included many restaurant chain operators) that they had in their database for the Cobb and Douglas area to advertise the opportunity to participate and gain recognition for this achievement.

(6) CDPH Food Safety Partnership Panel video presentation entitled The Risk Factor Challenge—The Food Safety Partnership Panel videos enhance food safety practices beyond regulatory requirements and strengthens our partnership with the food service industry and community.  Each episode's panel consists of 4 panelists [one or more representatives from the food service industry, a consumer that resides within the community, and an Environmental Health manager, who serves as the host].  Any person in Cobb or Douglas that falls into the category of a food service operator, regulator, or consumer may be considered for panel participation.  This particular video emphasized the need to improve upon the results observed during the Risk Factor Study via the implementation of intervention strategies with an added emphasis on Employee Health and the EHA campaign.

(7) The Georgia public health districts via the 2018 District Food Standards Conference- The CDPH Center for Environmental Health was asked to provide a presentation on the Fisk Factor Study and Employee Health Achievers program at the 2018 District Food Standards Conference so that all of the district Food Program Standards from across the state of Georgia could understand the program components and take the information back to their respective districts and use it as they desire.

(8) Presentation during the Fall 2019 meeting of the Georgia Food Safety Task Force.  The Georgia Food Safety Task Force is comprised of representatives from not only district level Food Safety officials but those from the State and Federal levels, including Epidemiologists, Environmentalists, State Laboratory representatives, USDA and FDA field representatives, and consultants, along with academia, food service industry representatives and consumer representatives.  The presentation at the task force meeting was how the Georgia Restaurant Association was officially introduced to the EHA campaign.

Regarding challenges, the biggest challenges have been the initial determination of how much information needed to be tracked per project participant, how often to track it, and how much time was needed to monitor and send out the certificates and other means of recognition.   However, after the first couple of months, it was determined that updates to the website and certificates would only occur once a month.  To help ensure that operators in all areas of the Cobb & Douglas community were being informed in person about the project, the field inspectors maintained a log of facilities that they introduced to the campaign within their district.  Another challenge that has occurred during this period has been a larger turn over in food inspection staff and the amount of food service management turnover.  The good thing regarding the training experience in this area for new staff is that the protocol for Employee Health Achievers introduction has become a part of the protocol for routine inspections which is made simple by use of the STOP Alert placards that provide a quick summary. The end result has made the efforts worthwhile.

After exposure to the program, EHA Learners will be able to:

1) understand and demonstrate how having specific protocols and controls in place can minimize the potential for food workers to work while sick and reduce the potential of a foodborne illness outbreak.

2) understand the importance of timely communication with the health authority and that the health authority is a resource when developing an effective employee health compliance program.

3) access and use additional resources available to assist with employee health compliance and outbreak prevention and response

4) respond effectively to Employee Health related information provided by food workers.

Recipients of the information provided during the EHA campaign benefit even if they don't commit to taking the quiz due to the way the requirements for Employee Health compliance is simplified.

No capital costs were incurred while developing or implementing the Partnership Panel video introducing the program. Douglas Communications does not charge the department for the filming nor editing of the Partnership panel videos.  They also host them on their local channel and allow them to be freely shared with Cobb County's Communication Department for airing.  The panel video containing the EHA overview is also available on the CDPH website upon demand.  In addition, the AFDO small projects grant that funded the production of the hard copies of the Employee Health RED Books-- as well as the special paper for printing the certificates and STOP Alert placards-- is competitively available to local health departments across the US that have enrolled in the FDA Retail Food Program Standards.

We will use the MAPP process to present the evaluation:

  • Create a healthy community and a better quality of life. The Institute of Medicine notes that "health is…a positive concept emphasizing social and personal resources as well as physical capabilities" (Improving Health in the Community, 1997, p. 41).  A "healthy community" goes beyond physical health alone. The community that we impact does not just consist of people within our district. We freely share the Employee Health Achievement model with regulatory staff in other districts and make the tools available on our website enabling access by food industry operators, regulators and the general public.  The emphasis that we have placed on good employee health & hygiene practices has helped to better protect the health of the public by contributing to the service of safe food from food service facilities within the Cobb and Douglas communities. 

  • Increase the visibility of public health within the community. One of the means for introducing the EHA campaign is via an episode of the district's Food Safety Partnership panels.  Consumers, operators, and regulatory professionals view the panel discussions via the local cable access channel, Vimeo, and the CDPH website for the purpose of education and/or entertainment and often trigger conversation between consumers/operators with the health authority.  In addition, the colorful certificates posted in area establishments recognizing that facility management has met the requirements for Employee Health Achievement are recognized by consumers and operators and exemplify the color scheme/branding of Cobb & Douglas Public Health.  The STOP Alert placards that we provide to food service operators are available for download by any food service operator not just those in the CDPH health district and have the same identifiable color scheme.

  • Anticipate and manage change. Program components have been easily adjusted upon the recognition of need.  For example, after the presentation of mock quizzes to a sample audience, the need for wording changes of a couple of questions was identified. Making modifications was easily accomplished via the Survey Monkey platform.  In addition, a modification to the EHA recognition requirements was made after a local health district asked what would happen if an establishment listed on our website was found to be out of compliance in the area of Employee Health.  It was acknowledged that as management changes, new management may not be well-versed in the area of employee health which in turn could affect compliance within the facility. Thus, a provision was added to the recognition program requirements and facility operators notified via mailing and posting on the CDPH website that posted names were subject to removal from the website if the facility was ever found in non-compliance regarding employee health on 2 consecutive inspections.
  • Create a stronger public health infrastructure.   We have a diverse network of partners within our local public health system that have helped make this project a success.  From the support of our Health Director and Environmental Health Director, to our local Environmental Health Specialists, to those in other counties and industry partners such as the Georgia Restaurant Association (along with the Georgia Food Safety Task Force) that support us in spreading EHA program information, to the food service operators and citizens that willingly participate and share their experiences, to our State Office of Environmental Health that allowed us to modify and print the Employee Health RED Books, and our local government support via Douglas Communications and Cobb Communications for the marketing of the Food Safety Partnership panel videos, we have a strong network that has enhanced Employee Health compliance within the health district.
  • Engage the community and create community ownership for public health issues.     Where there is knowledge there is power.  The information shared via the Employee Health Achievers program helps to remove excuses for non-compliance in the area of employee health by helping to improve the understanding of the regulatory components required of the Food Service Regulations.  It helps to equip our operators, regulators and general public with the tools to make informed decisions, recognize areas for change, and have knowledge-based discussions in the area of employee health & hygiene.  It is not uncommon to find owners of food service facilities within the district that have become advocates for the CDPH Food Service Program by helping to share our theme with others:  Think Food Safety.

The information shared during the program will improve understanding and compliance regarding employee health among operators and regulatory staff.  This face-to-face and online training & recognition program may be shared with-- and duplicated by-- other health districts.

Utilizing public access channels from local government to get out information regarding the EHA program via the Food Safety Partnership Panel video served the campaign well in that the video is still able to be accessed by viewers (the general public, food service industry workers, and regulatory officials) and there is no cost incurred on the health district.  The opportunity to advertise similar programs is likely to be afforded to other local health departments by local government access channels  throughout the United States because such channels are often starving for content, so their programming manager may be very eager to consider a well-articulated proposal from their nearby Environmental Health representative. 

Printing costs for certificates are minimal (coated paper and toner for a color printer).  The costs for website maintenance and a commercial Survey Monkey account are routine expenses paid by CDPH. 

Also note that there are opportunities to enhance participation along the way if it seems that a boost in participation is needed.  For instance, to help keep the promotion of the program going in the field, recognition is given to the Environmental Health Specialist with the highest number of operators that have successfully completed the EHA quiz during a CDPH Food Team meeting each quarter.  That team member is given a certificate of recognition to post at their workstations.

I am a previous Model Practices applicant