D IVISION /O FFICE :
S ECTION :
M EMBERS :
P D C
S T O R Y B O A R D
Division of Health Promotion
Environmental Health Section
Maria Almanza, Joe Durczak, Dan Eder, Kristin Johnson, Amy
Lantis, Juan Magana, Vic Mead, Neal Molnar, Austin Schramer, Liz
Swanson, Ben Sylejmani, Sharon Verzal, Julie Wiegel
P ROJECT T ITLE : Routine Food Inspection Report Completeness
D ATES OF P ROJECT : January 9, 2013 – July 10, 2013
Identify an opportunity and
Plan for Improvement
1. Getting Started
To standardize a process for how routine food inspection forms are filled the EH Section will see an increase in the percentage of completely written
inspection reports from 42% to 80%.
3. Examine the Current Approach
On 02/13/2013 the EH staff were anonymously surveyed regarding how out, the Environmental Health (EH) often they fill in each of the required staff met and developed criteria that fields on the inspection report. EH staff led to the creation of a checklist to use then each completed flowcharts to to review inspections for consistency. indicate their individual processes for
Inspections were initially audited by completing inspection reports. Both the supervisors using this checklist, but tools showed variability in the to limit subjectivity the supervisors met procedures among the staff members. to test their internal consistency in how the checklist was being used to review inspection reports.
Previously there was not a system
To determine the root causes of the problem the EH staff members conducted a Cause and Effect Diagram during a meeting on 03/05/13. developed to standardize how the forms were being filled out, so the project created an opportunity to improve the quality of reports being
Cause & Effect Diagram
Kane County Health Department, Environmental Health Section
Created: 3/5/13, Last Update: 3/5/13 given to food establishments.
Inspections audited from February of
2013 found that 42% of inspections were in compliance when using the newly created checklist.
2. Assemble the Team
Environment
Know what needs to
Be written, unsure of
How to write it
People
Mixed messages
Materials/Resources
Rushed
Not enough time
Workload
Short staffed
Multiple assigns.
Existing p/p manual is not helpful
Too general
No real life examples
Conflict of two separate systems:
Establishments want simple/concise reports,
State & codes require lots of detail
System requires rushing to complete the work
Interruptions
Busy restaurant
Emergencies
Unsure what “correct” means
We don’t believe in what we’re doing (some things
Feel redundant, unnecesary)
Hard to change habits
Less money, more work = unmotivated, feel unvalued
Forget
Resistance from establishment
Information not posted/
Available at establishment
Confused by multiple messages
Don’t have time to
Review p/p
We don’t follow up on
Missing information
Time/workload constraints
Best practices are not broadly
Shared (1 person is told)
Unsure what “correct” means
Get marked down for blanks
Where blanks are valid ( no “N/A”)
Form design not conducive to
Fill out correctly
Too crowded/overwhelming
Missing necessary fields
Poor placement of fields
Budget limitations
Inspection forms are
Not filled out completely
And accurately
Unspoken “quantity
Over quality” policy
Too many codes/ordinances:
Unsure which to follow
Redundancies on form (e.g. scores, info we have on their application)
Priority is to get them done (quantity over quality) Rushed
Feel some fields unimportant, so skip them
Motivation/Incentives
Inconsistencies in training
Methods/Procedures
·
MAJOR ROOT CAUSES:
Conflict of establishment needs & requirements of code
·
Inconsistencies in messages, training
· received, definition of
“correct”
Pressures of time and
· workload
Lack of group collaboration on this issue
The entire Environmental Health
Section of nine Environmental Health
Practitioners, two Program Supervisors, one Administrative Assistant, and one
Assistant Director were involved in the process. All team members had an active role in the discussion, design,
Based on the result of the Cause and
Effect Diagram, some of the root causes determined were inconsistency in assessment by the supervisors, pressures of time and workload, and not enough group collaboration in defining what a completely written inspection form is. and implementation throughout the
PDCA process. From the results of the
February baseline data an Aim
4. Identify Potential Solutions
Statement was created: By 05/13/2013,
On 03/13/13 the EH group talked about best practices around how inspection reports are written and looked at potential solutions to ensuring completeness of inspection reports.
The EH staff brainstormed potential solutions and created an Affinity
Diagram to identify the best possible method of improvement.
Creating Completeness and Uniformity Among Environmental Health Practitioners
Inspection Form
Design
Change the flow of the inspection form
Elimination of
“unimportant” fields on inspection report
Form Design
Time and
Workload
Focus on quality over quantity
Average time to complete inspection expectations
Less workload so we have more time and aren’t as rushed during inspections
Assessing
Completeness
Forgetting to write in every aspect prior to giving yellow copy
Completeness vs. correctness:
What by definition is correctness?
Explain/review each
“info” area with operators as you go over report to make sure info filled in and correct
Review inspect report to check for completeness in your car after inspection
Creating a
Guide/Checklist
Creating a guide of why it’s a violation
Providing examples of violations
Show examples of violations to
ALL sanitarians
Creating a checklist
Checklist of what needs to be completed
Training,
Consistency, and
Collaboration
Training to know what needs to be written
Sit down as a big group and talk instead of small groups
Continue with group collaborations to help maintain group consistencies
Provide consistent trainings so that everyone is on the same page
Created on 03/13/13 during Environmental Health Section Meeting
Based on the Affinity Diagram results and previous discussions, the group voted and selected to create an
Inspection Standardization Form. This served as tool to use in the field in which EH staff had an identified list of what should be written on the inspection form and how it should be written. The form supplied EH staff with concise guidelines for standard inspection documentation.
5. Develop an Improvement Theory
In selecting the creation of an
Inspection Standardization Form, the prediction was that if each EH
Practitioner brought the guide and used it after each routine inspection, then the percentage of correctly

written inspection reports would increase from 42% to 80% by
5/13/2013. The form was created by the team to address the identified root cause of inconsistency and to ensure group collaboration, and the final version of the form was handed out to use between 04/13/2013 to 5/13/2013.
34
Food Service Establishment
Retail Food Store
Summer Food Program
Mobile - Truck, Trailer, Pushcart
Other
1240 N. Highland Ave., Ste. 5, Aurora, IL 60506
Phone (630) 444-3040 Fax (630) 897-8123
1750 Grandstand Pl., Ste. 2, Elgin, IL 60123
Phone (630) 444-3040 Fax (847) 888-6458
F OOD ES T ABLIS HME N T IN S P E CT ION
RE P ORT
Address
6
Establishment Number
2
Establishment Category
Routine Inspection
4
Follow-Up Inspection
3
Other
Name of Establishment
Owner or Operator
5
E-mail
Basic Food Safety Training 11
Sanitizing
# Trained 12
Temperatures: Hot Foods
Temp.
13 Item Temp Item
Phone
Based on an inspection this day, the items marked (x) below identify violations of the Kane County Health Ordinance and/or the State of Illinois Rules and Regulations adopted under this ordinance.
Failure to correct these violations within the time specified may result in immediate cessation of all food establishment operations and/or the possibility of further legal action.
14
15
16
17
CRITICAL ITEMS REQUIRE IMMEDIATE CORRECTION
ITEM X WT
1
2
3
DESCRIPTION
FOOD
5 Source, Wholesome. No Spoilage
1 Original Container, Properly Labeled
FOOD PROTECTION
5 Potentially hazardous food meets temperature
4
5
6
7 requirements during storage, preparation, display, service and transportation
4 Facilities to maintain product temperature
1 Thermometers provided and conspicuous
8
9
10
11
12
13
2 Potentially hazardous food properly thawed
4 Unwrapped and potentially hazardous food not re- served. CROSS CONTAMINATION
2 Food protection during storage, preparation,
35
1 Food (ice) dispensing utensils properly stored
PERSONNEL
5 Personnel with infections restricted
5 Hands washed and clean, good hygienic practices
1 Clean clothes, hair restraints
F OOD EQUIPMENT AND UTENSILS
2 Food (ice) contact surfaces: designed, constructed, maintained, installed, located
1 Non-Food contact surfaces: designed, constructed, maintained, installed, located
2 Dishwashing facilities: designed, constructed, maintained, installed, located, operated
1 Accurate Thermometers, chemical test kits provided, gauge cock
ITEM X WT
18
19
20
21
22
DESCRIPTION
1 Pre-flushed, scraped, soaked
2 Wash, rinse water: clean, proper temperature
4 Sanitization rinse: clean, temperature, concentration
1 Wiping cloths: clean, use restricted
23
24
25
26
2 Food-contact surfaces of equipment and utensils clean, free of abrasives and detergents
1 Non-food contact surfaces of equipment and utensils clean
1 Storage, handling of clean equipment -- utensils
1 Single-service articles, storage, dispensing
27
28
2 No re-use of single-service articles
WATER
36
5 Water source, safe: Hot and cold under pressure
SEWAGE
4 Sewage and waste water disposal
29
30
31
32
33
PLUMBING
1 Installed, maintained
5 Cross-connection, back siphonage, back flow
TOILET AND HAND WASHING FACILITIES
4 Number, convenient, accessible, designed, installed
2 Toilet rooms enclosed, self-closing doors, fixtures, good repair, clean; Hand cleanser, sanitary towels/hand drying devices provided, proper waste receptacles, tissue
GARBAGE AND REFUSE DISPOSAL
2 Containers or receptacles covered; adequate number, insect/rodent proof, frequency, clean
ITEM X WT
34
35
DESCRIPTION
1 Outside storage area, enclosures properly constructed, clean; controlled incineration
INSECT, RODENT ANIMAL CONTROL
4 Presence of insects/rodents -- outer openings protected, no birds, turtles, other animals
FLOORS, WALLS AND CEILINGS
36
37
38
39
40
41
42
43
44
45
9
1 Walls, ceiling, attached equipment: constructed, good repair, clean surfaces, dustless cleaning methods
LIGHTING
1 Lighting provided as required -- fixtures shielded
VENTILATION
1 Rooms and equipment -- vented as required
DRESSING ROOMS
1 Rooms clean, lockers provided, facilities clean
OTHER OPERATIONS
5 Toxic items properly stored, labeled and used
1 Premises: maintained, free of litter, unnecessary articles, cleaning/maintenance equipment properly stored, authorized personnel
1 Complete separation from living/sleeping quarters, laundry
1 Clean, soiled linen properly stored
Certified Food Manager Yes No
C.F.M. 10 I.D.# Exp. Date
Temp Item
Temperatures: Cold Foods
Temp Item Temp
3-Comp.
14
Dish Mach.
Wiping Cloth
15
17
20
ppm
ppm
ppm
22 23
Item
24
Remarks and Recommendations for Correction Correct By
26
25
Date
27
Report Received by
Time
32
28 in
29 out Preliminary Score
30
33
(Signature of Owner or Representative)
(Sanitarian)
Final Score
(100 Minus Demerits)
31
Inspected by
During this period each routine inspection was evaluated by the EH
Supervisors using the inspection review checklist, the same version used to establish the February baseline data.
Test the Theory for Improvement
6. Test the Theory
Because the team anticipated that improvements may be seen just by identifying and working through the
PDCA process, data was collected from
February 2013 until the end of the
PDCA cycle. The data was collected and analyzed by the two EH
Supervisors. Bar charts created showed monthly results for each EH
Practitioner and a group average based on the percentages of violations written correctly, percentages of forms filled out correctly, and percentage of completely written reports. Bar charts were created for February, March,
April, May (May 1-13), and from during the implementation period of April 13-
May 13.
A line chart from February 2013 to May
2013 demonstrated the percentage of completely written inspection reports.
Completely Written Inspection Report Average
60%
50%
40%
30%
20%
10%
0%
100%
90%
80%
70%
February March April mid-May
Individual line charts for each EH
Practitioner showed by week the percentage of completely written inspection reports throughout the entire PDCA process. Trend lines were put into these graphs to show an average positive or negative trend.
All individual data was displayed anonymously.
Use Data to Study Results of the Test
7. Check the Results
Data showed an increase in completely written inspections from 42% in
February to 75% by end of the PDCA cycle (05/13/2013). The data showed increases by month in average percentages of correctly written violations, forms, and completely written reports. Individual data also showed increases by every
Environmental Health Practitioner, though variations in the degree of improvement. This variability is an issue for further investigation.
Standardize the Improvement and
Establish Future Plans
8. Standardize the Improvement
or Develop New Theory
While the improvement did not reach the desired goal of 80%, the increase from the baseline of 42% to 75% at the end of the PDCA cycle was deemed a success by the team. On 07/06/13 the team evaluated the Inspection
Standardization Form via a SWOT analysis. The analysis revealed an increased level of consistency and team collaboration, but the team felt the development process was time consuming. The SWOT also identified opportunities for new projects.
To standardize the improvement, the
Inspection Standardization Form is now standard practice and serves as a tool that EH Practitioners use during their inspections. The form has also been implemented into the process for new employee training. To sustain the gains, the EH Section will continue to monitor this data on a quarterly basis as part of the KCHD Performance
Management System. Declines in performance could result in future
PDCA work.
9. Establish Future Plans
There were numerous future plans that arose throughout the PDCA process, such as creating a future PDCA around what is considered a “correctly” written violation, possible changes to the current inspection form being used, and possibly utilizing the project as a driving mechanism towards digital inspections in the future. To celebrate the success of the project future plans include distribution of results internally and with external partners via newsletters, as well as sharing with regional and national organizations in the areas of EH and quality improvement.