Introduction
Sacramento County is located in California's central valley, a vast agricultural region that extends nearly 1,000 miles. Sacramento is the California state capital, home to over 1.4 million people and host to over 6 million visitors per year. Sacramento County includes seven incorporated cities, a large unincorporated area, and nearly 7,000 retail food businesses. Sacramento County is governed by a five-member board of supervisors and has over 14,500 employees. Within the county, the Environmental Management Department (EMD) is responsible for providing mandated regulatory services in environmental health, hazardous materials, and water protection. The Environmental Health Division includes the Retail Food Protection Program, which is charged with ensuring that all retail food facilities are permitted and routinely inspected for compliance with the California Health and Safety Code. The overall goal is to ensure that food served to the public is stored, handled, prepared, and served in a pure and safe manner, thus reducing the occurrence of foodborne illness. Retail food facilities countywide, including restaurants, markets, schools, bakeries, bars, licensed health care facilities, certified farmers' markets, community events, and mobile food vendors are monitored by the division. In addition to conducting routine inspections to ensure compliance with state and local health and safety codes, environmental specialists also provide food safety education and investigate consumer complaints of foodborne illness and sanitation for retail food facilities.
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Additional consumer protection programs for Sacramento County include recreational health, plan review, tobacco licensing, childhood lead poisoning prevention, employee housing, detention facilities, and noise abatement.
In 2008, the total budget for the Retail Food Protection Program was just over $4 million. EMD receives no general fund monies and is fully funded through permit, reinspection, and consultation fees paid by the 7,000 permitted retail food businesses. In May 2007, a comprehensive five-year fee ordinance package was submitted to the county's board of supervisors to ensure full cost recovery for all program services. The fee ordinance package was approved and is effective until 2012.
Retail Food Program Enhancements
From 2002 to 2007, several multifaceted enhancements for its Retail Food Protection Program were initiated. These enhancements were developed in an effort to 1) improve food safety practices and awareness, 2) reduce foodborne illness, and 3) improve public disclosure methods of inspection results at retail food facilities. During this period, EMD focused primarily on reducing the occurrence of major violations in food facilities. Major violations are based on the risk factors identified by the Centers for Disease Control and Prevention (CDC) as most likely to be associated with foodborne illness.
In 2002, EMD's Retail Food Protection Program received heightened attention from the media and the public, highlighting the need for more frequent food facility inspections, strengthened enforcement processes, and improved disclosure of inspection results. This attention provided the opportunity for EMD to collaborate with the retail food industry, the public, and local governing bodies to improve food safety and prevent foodborne illness in Sacramento County. As a result, in 2003, EMD launched into the development of several Retail Food Protection Program Enhancements--Phases I and II.
Phase I--2003-2005
Several key goals were established for the execution of Phase I enhancements.
* Public Disclosure of Inspection Results. Media attention and public comment revealed an interest in disclosure of inspection results. California state law already required facilities to post a sign stating that the last routine inspection was available and could be requested by a patron. To take this a step further, the board of supervisors approved a local ordinance in 2003 requiring retail food facilities to post their last inspection report in a location easily visible to patrons upon entering the facility. This afforded the public with easy access to complete health inspection reports and the opportunity to make fully informed decisions regarding their dining choices, while eliminating the need for the patron to make a formal request for the information.
* Web site. In 2003, EMD also significantly enhanced internet accessibility of inspection reports by posting copies of health inspection reports on its public Web site. Through a streamlined search mechanism, the public is able to view inspection reports by entering the name of business, partial name of business, or street address (Figure 1).
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* Awards of Excellence in Food Safety. In the midst of numerous program changes, it was important to reward and recognize those operators who had successfully achieved compliance on a consistent basis. In 2004, EMD began to issue Awards of Excellence to facilities that consistently maintained exemplary inspection histories as demonstrated by having no major violations documented over two consecutive routine inspections. Awards are issued to approximately 10% of facilities each year. In an effort to celebrate this achievement, EMD holds a recognition event each September during Food Safety Education Month and randomly selects recipients to receive their award before the local governing board. The Awards of Excellence have become a significant component of the program as they provide a positive incentive for operators to improve their food safety practices. A list of award recipients is posted on EMD's Web site at www.emd.saccounty.net.
* Risk-Based Inspections. In 2001, the California Health and Safety Code was modified to place an emphasis on those items identified by CDC as the leading risk factors associated with foodborne illness. Prior to 2002, all retail food establishments in the county received one routine health inspection per year. Phase I enhancements incorporated a risk-based approach. Inspection frequencies were increased from one to two per year for open food preparation facilities, while inspection frequencies for packaged food facilities remained at one inspection per year. The addition of eight full-time staff was necessary to achieve the increased inspection frequency goals.
* Mandatory Food Safety Education. In 2003, the Sacramento County board of supervisors approved another ordinance requiring all food handlers and managers of establishments where major food safety violations are repeatedly documented to attend an FSE class or 'Food School.' Environmental specialists teach the course and cover basic food safety principles and practices. FSE creates a unique environment for both operators and specialists to communicate in a setting outside of the distractions found in a food facility. Due to the diversity of EMD staff, FSE is offered in English, Spanish, Cantonese, Punjabi, and Korean. A modest fee of $20 per person is required and the course is taught several times per month at EMD offices.
Since 2003, over 3,500 foodservice employees representing 900 food facilities have attended the classes. To date, over 300 classes have been taught by EMD staff and marked improvements in food safety practices at the food facilities have been demonstrated. A data review of documented violations at the facilities that attended FSE over a period of five years revealed a 50% reduction in the number of major violations after the class was completed (Figure 2).
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* Enforcement Procedures. As important as education is in the reduction of major risk-factor violations, properly executed enforcement procedures are also recognized as key factors in any successful retail food safety program. In 2002, enforcement procedures consisted solely of reinspections and the associated fees for these services. Specialists were often burdened with making several visits to a facility in order to move forward with enforcement procedures. It was evident that improvements to the enforcement process were needed. In 2004, EMD instituted the use of compliance conferences to more effectively address the issues of noncompliant operators. Compliance conferences are held when reinspection fees and FSE attendance have not improved the facility's food safety practices. Compliance conferences are held at EMD offices, and facility owners are required to attend the conference with a supervising environmental specialist as the compliance officer. Compliance conferences are designed to create a one-on-one interaction with the responsible party or permit holder of a noncompliant food facility. Major risk-factor violations are discussed in detail and a formal contract agreement is made for the abatement of documented violations and the achievement of long-term compliance.
Phase II--2005-2008
The implementation of Phase I enhancements signified tremendous growth and progress within Sacramento County's Retail Food Protection Program. Once all components of the enhancements were implemented, the original goals were revisited. Had the enhancements successfully reduced major violations? Improved disclosure of inspection results? Increased outreach and education? The answers to these questions promptly gave rise to Phase II enhancements.
Although major violations were certainly reduced with increased inspection frequencies, a data review in January 2005 revealed that 40% of all
food preparation facilities still had at least one major violation recorded during their routine inspections, while 25% of all prepackaged facilities showed incidence of major violations during their routine inspections. The statistics were clear, yet unacceptable. The decision was made to increase inspection frequencies for all fixed food facilities, including food preparation and prepackaged food facilities.
In addition to an examination of trends in major violations, the enhanced disclosure methods that were implemented were also reviewed. A similar survey was conducted to determine compliance with the county's report posting ordinance. It was discovered that a surprising 50% of all establishments were either not complying with the ordinance by not posting their reports entirely, or were not following the letter of the ordinance by posting inadequately In addition, strong feedback was received from members of the public. The public did not find the posting of the inspection reports useful for their dining decisions. Reports were often difficult to read, handwritten, and contained technical jargon that was difficult to decipher. The public requested a quick, simple, and instant food safety message for their favorite eateries.
In response to these results, EMD launched a new disclosure system for the retail food establishments within the county. Taking the lead from Toronto, Canada, Sacramento County adopted a color-coded placard system which became effective on January 1, 2007. This was a significant leap as it was the first of its kind in the United States for the disclosure of routine health inspection results.
The following is an overview of the Phase II Retail Food Program enhancements.
* Posting of Color-Coded Placards for Disclosure of Inspection Results. In May 2006, the board of supervisors approved a local ordinance requiring the posting of color-coded placards following each inspection at fixed retail food facilities. The placard is required to be displayed so that it is visible to the public prior to entering the facility. A facility will be issued one of three possible placards: a green placard, a yellow placard, or a red placard. A green placard signifies 'pass' and is posted if no more than one major violation was observed during the inspection. A yellow placard is posted indicating a ' conditional pass' where two or more major violations were observed during the inspection. Following the issuance of a yellow placard, a reinspection is required within one to three days. Additionally, all major violations must be corrected during the inspection. The yellow placard remains posted until the specialist confirms that the major violations noted on the routine inspection remain corrected at the time of reinspection. A red placard reading 'closed' indicates closure of the facility due to an immediate danger to the public health or safety. After receiving a red placard, a facility must stay closed until a subsequent reinspection reveals abatement of the identified dangers to public health. See Figure 3 for a view of the placards.
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The color-coded placard rating system is based entirely on major violations stemming from five primary risk factors identified by the CDC: improper holding temperatures, poor personal hygiene, contamination, inadequate cooking, and unsafe food sources (CDC, 1996 and 2006). The new disclosure system has produced the dual benefit of improving public disclosure of inspection results and emphasizing the importance of compliance with major risk factor code requirements.
During the first few months of 2006, the percentage of yellow placards issued was approximately 13%. In early 2009, statistics show a marked reduction in major violations: the issuance of yellow placards has reduced to approximately 9%. The issuance of red placards has remained steady during the last two years at 1%.
* Increased Inspection Frequencies. In an effort to reduce the occurrence of major violations, inspection frequencies for food preparation facilities increased from two inspections per year to three inspections per year. The frequency of inspections for packaged food facilities increased from one inspection per year to two inspections per year.
* Increase in Inspection and Support Staff. The proposed increase in inspection frequencies created a demand for additional staff. In order to conduct the increased number of inspections for 5,500 food facilities, an additional nine full-time inspection and administrative support staff were added.
* Registered Environmental Health Specialist Training Program. During the last several years, California has seen a statewide shortage of trained Registered Environmental Health Specialists. Specialists must pass a Registered Environmental Health Specialist exam in California. EMD established a training coordinator position and initiated an expanded training program to create a larger pool of qualified candidates.
* Outreach and Education. The Food Safety Education course that was established in Phase I for employees of facilities with documented major violations continues to be an educational resource for food service industry employees. Additional classes were also offered several months in advance of color-coded placard implementation to provide an overview of the new system. These 'How-to-Get-a-Green Placard' classes are offered in five languages: English, Spanish, Cantonese, Korean, and Punjabi. These 90-minute courses, taught by environmental specialists, thoroughly explain the new disclosure system and provide an overview of basic food handling principles necessary to avoid major violations. 'How-to-Get-a-Green Placard' classes are offered at EMD offices, per request at facility sites, as well as in libraries and various community centers throughout the county. An instructional DVD has also been created to enable food operators to conveniently provide training to their staff. The DVD was filmed in a commercial kitchen and professionally narrated. DVDs were mailed to all 5,500 fixed retail food establishments within the county. A view of the cover is provided in Figure 4.
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In the six months prior to implementation of the placard system, Sacramento County staff began conducting field trials. At the conclusion of routine inspections at fixed retail food facilities, the specialist reviewed the findings with the operator and informed them which placard would be received under the new color-coded placard system. The field trial period provided each operator with the opportunity to have a one-on-one explanation of the system. The operators also received specific information regarding improvement areas, thus setting the stage for operator success with the new disclosure system. Posters and compliance assistance bulletins in English, Spanish, Cantonese, Punjabi, and Korean were also distributed during the field trial inspections (Figure 5).
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* Consistency of Inspections. The process of standardizing inspection techniques was extremely important to the food industry, especially with the new and highly visible placard system in place. EMD has been committed to ensuring that standardization training is provided regularly and will continue to provide training for environmental specialists to assure consistency during inspections.
In late 2006, Sacramento County EMD published a Retail Food Inspection Field Guide. This guide was designed to clarify and interpret each code section while providing real-life major and minor violation examples for each. It was distributed to all 5,500 retail food facilities as well as to each environmental specialist. The guide became, and still is, an important standardization tool, essential for the fair implementation of the new disclosure system.
* Enforcement. To enhance and solidify the enforcement process, several additions were made to existing internal policies and procedures. These additions included administrative hearings, permit suspensions, and permit revocations. A list of facilities that receive red placards is posted on EMD's Web site. The list is updated each month. Implementation of these new enforcement processes has produced tangible improvements in several cases, particularly with food facility operators with extended records of noncompliance.
Conclusion
The population, number of retail food facilities, and needs of the business community within Sacramento County have steadily increased over the last several years. The Retail Food Protection Program has nearly tripled in size and is now well recognized for the type and quality of services provided to the retail food industry and the public. Public awareness and demand for improved food safety will continue to drive community support for the program, due in large part to an innovative and highly visible disclosure system, and national media attention to food-safety issues.
The program enhancements implemented during the last six years have had a momentous impact on food-safety awareness among the retail food industry and the residents in Sacramento County. EMD's Web site receives over 100,000 hits per month, which is indicative of overall public awareness and interest in the information now available. The program enhancements were implemented in the interest of accomplishing EMD's mission and educating both the retail food industry and consumers in order to reduce foodborne illness. The success of the program must be attributed to the collaboration and input by each of our stakeholders, including EMD's retail food industry working group, the Sacramento environmental commission, the Sacramento County board of supervisors, the business community, the public, and the extraordinarily competent and talented EMD staff. We recognize that these efforts must be ongoing, and we intend to continue to seek innovative ways to perfect our programs in order to improve food safety practices for consumers at the retail level, including the over 1.4 million residents and over six million visitors of Sacramento County.
Acknowledgements: The authors would like to acknowledge the valuable contributions of the staff from EMD's Environmental Health, IT, and Administrative Support Programs:
* Mel Knight, R.E.H.S.;
* Richard Sanchez, M.P.H., R.E.H.S.;
* June Livingston, R.E.H.S./Communication and Media Officer;
* Kerri Aiello, Communication and Media Officer; and
* Sylvanus Thompson, Ph.D., M.Sc., CPHI(C), Quality Assurance Manager, Toronto Public Health, Toronto, Canada.
Corresponding Author: Alicia Enriquez, Program Manager, Sacramento County Environmental Management Department, 8475 Jackson Road, Suite 240, Sacramento, CA 95826. E-mail: EnriquezA@SacCounty.net.
REFERENCES
Centers for Disease Control and Prevention. (1996). Surveillance for foodborne disease outbreaks--United States, 1988-1992. Morbidity and Mortality Weekly Report Surveillance Summaries, 45(No. SS-5). Retrieved January 12, 2009, from http://www.cdc.gov/mmwr/PDF/ss/ss4505.pdf
Centers for Disease Control and Prevention. (2006). Surveillance for foodborne disease outbreaks--United States, 1998-2002. Morbidity and Mortality Weekly Report Surveillance Summaries, 55(No. SS-10). Retrieved January 12, 2009, from http://cdc.gov/mmwr/PDF/ss/ss5510.pdf
Editor's Note: The Samuel J. Crumbine Consumer Protection Award for Excellence in Food Protection, named in honor of one of the most renowned U.S. public health sanitarians, is presented each year to a local public health agency by a jury of leading environmental health officials and public health sanitarians. The Crumbine Award is the most prestigious recognition that a public health agency can receive for excellence and improvement in food protection. Agencies that win the Crumbine serve as models for other public health and safety programs across the nation.
In this report, readers will find a review of the Sacramento County Environmental Management Department's program, winner of the 2008 award. The description is adapted from information the department submitted on its Crumbine application. For more information about the Crumbine Award, please contact Lynn Dyer, director of Market Development and Programs at the Foodservice & Packaging Institute (FPI), at (703) 538-2800. For more information about the Sacramento County Environmental Management Department, contact Val. F. Siebal, director, at SiebalV@SacCounty.net, John Rogers, division chief at RogersJo@SacCounty.net, or Alicia Enriquez, program manager, at EnriquezA@SacCounty.net. A copy of Sacramento County's entire award-winning application is posted on the FPI Web site at www.fpi.org.
Alicia Enriquez, R.E.H.S.
Zarha C. Ruiz, R.E.H.S.
Jannine Talusik, R.E.H.S.
