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Using an Active Managerial Control Toolbox to Reduce Foodborne Illness Risks

State: AZ Type: Promising Practice Year: 2020

Maricopa County is the most populous county in Arizona and the fourth most populous county in the United States. In addition to the 4.4 million residents, it is estimated that 22 million people visit annually. About half the population of the County is Caucasian, with Hispanic as the largest minority. Maricopa County is uniquely diverse, as 26.6% of the population speaks a language other than English at home.


In the past, Maricopa County Environmental Services Department (MCESD) required establishments that faced legal action after three repetitive Priority (critical”) violations to attend a training class in Active Managerial Control (AMC). Up to that point, these establishments had demonstrated an inability to control serious foodborne illness risk factors. The 218 establishments that faced legal action in 2013-2017 averaged 2.04 Priority violations/inspection prior to the AMC class, then after attending the AMC class, they averaged 0.71 Priority violations/inspection at the first post-class inspection, and 0.86 Priority violations/inspection at the fourth post-class inspection.


Based on these positive outcomes, MCESD strategy and policy now incorporate a comprehensive AMC-based inspection program with the goal of fostering proactive food management practices, reducing foodborne illness risk factors in the community, and preventing legal action on businesses. To scale up the AMC-based approach from the classroom to every inspection as recommended by the U.S. Food and Drug Administration (FDA) for over a decade new outreach materials were required, as well as advanced training for inspection staff to assess an establishment's level of AMC. Thus, the web-based AMC Toolbox (https://www.maricopa.gov/4533/English-AMC-Toolbox) was designed to empower managers at all levels to apply the principles of AMC by (1) setting policies for their operation (Policy”), (2) providing continuous training to staff (Train”), and (3) routinely checking that staff are following policies (Verify”), or PTV.


A five-year (2016-2020) FDA cooperative grant funded the AMC Toolbox project. The success of the AMC Class is illustrated in the step-by-step coaching of PTV, and the hands-on policy-writing exercise. Of note are the 31 short videos that consistently reinforce how to apply PTV to some of the major food-handling risk factors. As simple as this might seem, in many cases, managers lack the time and experience to put what they learned from a food safety course into practice on the ground, despite their best efforts.


Vast amounts of printed and web-based food safety materials are generally available on the internet. Uniquely, MCESD wanted simpler tools with a manager's point-of-view in order to appeal to the smaller, independent, mom-and-pop” food establishments who may not have the same time or resources as corporate establishments do to coordinate policies and training. Language and cultural barriers must often be overcome, and the rather casual nature of the videos of the AMC Toolbox may be more appealing to oral communicators as an alternative to more formal training.


The AMC Toolbox is a major, visible component of the comprehensive AMC-based food inspection program at MCESD. Inspection software was customized so that a hyperlink to the Toolbox web app can be inserted in the documentation of a violation. This is a convenient and effective delivery method of the relevant Toolbox resources that address the violation as the manager reads the emailed inspection report. Besides the videos, the Toolbox includes many new and redesigned infographic-style food safety posters and hand-outs, sample policy templates, and sample monitoring log templates for printing. The print library is available in English, Spanish, and Chinese; the translations of the English-language videos into Spanish and Chinese are in progress.


The Environmental Health Specialist (EHS) staff completed a Train the Trainer” class to learn how to guide and coach operators to become active managers by analyzing root causes of violations and following through with PTV. AMC assessment at the establishment is the foundation of inspections. Consistent exposure to PTV from the inspectors and easy access to the AMC Toolbox for reinforcement of those ideas is setting AMC as an expectation for every establishment in the County.


The MCESD AMC-based food inspection program is uncommon among governmental inspection programs. The FDA has long recommended risk-based food inspections and application of AMC principles in food establishments as an ideal. The AMC Toolbox is the result of several years' work towards this comprehensive AMC-based inspection program. The Toolbox project and its resources were presented to professionals and colleagues at eight conferences in the past four years, which resulted in interest and inquiries from members of several organizations.

The Phoenix metropolitan area has many food establishments. Typically, there may be 23,800+ food permits (including mobile food but excluding the special event temporary food”) that require 53,000+ inspections per year. Thus far in 2019 (1/1-12/26), 55,710 routine inspections, re-inspections, and verification visits” were conducted. This does not include 4,003 special event temporary food” routine inspections and re-inspections. Unfortunately, the recurrence of consecutive violations cannot be extracted with the current database architecture for reporting.


In the past, MCESD required establishments that faced legal action after three repetitive Priority violations to attend a training class in AMC. Over the previous year or more, these high-risk establishments had demonstrated an inability to establish control over serious foodborne illness risk factors. The 218 establishments that faced legal action in 2013-2017 averaged 2.04 Priority violations/inspection prior to the AMC class, then after attending the AMC training, averaged 0.71 Priority violations/inspection at the first post-class inspection, and 0.86 Priority violations/inspection at the fourth post-class inspection.


Given the positive response with this high-risk group of operators, MCESD has worked towards an innovative, comprehensive AMC-based food inspection program. As the web-based AMC Toolbox neared completion, the inspection software was customized to insert text and hyperlinks for 112 different code reference violations. (Not all Priority and Priority Foundation (less critical”) violations link to a Toolbox risk factor.) The invitational text "For a permanent fix to this violation, check out these simple tools in our Active Managerial Control Toolbox, made especially for you. https://www.maricopa.gov/....." links managers directly to the specific web app page for the risk factor at issue.


The AMC Toolbox web app and inspection report updates were ready in March 2019. Thus far (3/1-12/26), 45,936 inspections were conducted. Forty percent of those inspections had at least one violation of any level of severity (Priority, Priority Foundation, Core). Class 4 establishments are typically full-service restaurants and more complex operations. Thirty-nine percent of the 45,936 inspections were Class 4 permits. Of the inspections at Class 4 establishments, 41% of them had violations. From March to December, 63% of cited Priority violations (that is, 8,522) and 57% of cited Priority Foundation violations (6,404) occurred at the Class 4 establishments. (Again, unfortunately, the recurrence of consecutive violations cannot be extracted with the current database architecture for reporting.) Eighty-eight percent of all cited Priority violations and 85% of all cited Priority Foundation violations included the hyperlinked reference to the Toolbox.


The web-based AMC Toolbox expands the reach of the AMC Class to empower managers to practice AMC by (1) setting policies for their operation (Policy”), (2) providing continuous training to staff (Train”), and (3) routinely checking that staff are following policy (Verify”), or PTV. Less emphasis is placed on, for example, what food temperatures should be, and more focus on practical, step-by-step tips on how the manager can run the operation to ensure food temperatures are correct. With managers and minority-language groups in mind, 31 short videos (3 minutes or less) reinforce the AMC principles of PTV as they apply to major food-handling risk factors. One of the major challenges in working with the food service industry is that many times, regulators advocate the development of written policies to an oral culture. MCESD wanted simpler tools with a manager's point-of-view in order to appeal to the smaller, independent, mom-and-pop” food establishments who may not have the time or resources as corporate establishments do to coordinate policies and training.


MCESD inspection and enforcement policies were updated and aligned to create a comprehensive AMC-based inspection program. Ideally, correction of each Priority and Priority Foundation violation involves a root-cause analysis and evaluation of PTV. The EHS may offer an on-site AMC Training inspection at any time, free of charge. Likewise, an operator may request an on-site AMC Training inspection at any time. If a Priority violation of the same code reference occurs on consecutive inspections at an establishment, the EHS offers to formulate a risk-control plan” as a first step towards long-term correction of the foodborne illness risk factor. If a third repeat of the same code reference occurs at the following inspection, key staff from the establishment must register to attend an in-class AMC training or the establishment faces immediate legal action. The free, two-hour AMC Class is open to any establishment that wishes to attend and aims to expand the way managers think about how they control their operation and encourages the use of PTV to ensure violations are not occurring. The class includes step-by-step coaching and hands-on writing exercises for any cited risk factors with assistance from the instructor. If another repeat violation of the same code reference occurs at the next inspection, legal action is initiated.


The videos and printed materials for the AMC Toolbox were funded by a five-year (2016-2020) FDA cooperative grant that provided $70,000 per year to develop educational strategies for reducing the risk of foodborne illness. The creative talent that wrote, recorded, and edited the AMC training videos were eight Arizona State University students who applied for Maricopa County paid internships. The FDA funding covered the cost of video production software and hardware. The acting ensemble was comprised of 28 MCESD staff. The FDA grant also covered the printing costs of PTV posters, of which there are 35. With Spanish and Chinese translations, a total of 105 different infographic-style posters were created or redesigned by MCESD staff. A total of 123 guidance documents in English, Spanish and Chinese are also available in the AMC Toolbox. These include introductions to the AMC principles of PTV, example policy templates, and example monitoring log templates. The 6.3% difference between the FDA (10%) and MCESD (16.3%) indirect cost rates was absorbed by MCESD as in-kind cost.


MCESD worked with Maricopa County Enterprise Technology department and a third party to update the inspection software so that field staff could include hyperlinks to the web-based AMC Toolbox in the violation description in the inspection report. Propagation of the Toolbox materials is largely via inspection staff. While reading an emailed inspection report, managers can link to the web-based Toolbox for 122 frequently occurring code reference violations. New native app webpages were created by MCESD staff and Maricopa County Enterprise Technology on the Maricopa County app site for ease of use and navigation.


MCESD Enforcement Division updated its policies in support of the comprehensive AMC-based inspection program. Needless to say, operators frequently choose attendance at AMC Class over immediate legal action. Thus, legal actions on establishments with consecutive repeat Priority violations are postponed for the required AMC Classes. Reduced paperwork and workload will result if adoption of the AMC principles to the foodborne illness risk factor has long-term effectiveness and success.

In addition to reducing the risk of foodborne illness at establishments with the educational AMC Toolbox resources, more independent, mom-and-pop” operators might participate in the existing MCESD Cutting Edge Program, which is an alternative inspection program for establishments that demonstrate adherence to their PTV procedures. Currently, the Cutting Edge Program includes many proud franchise and grocery establishments that have corporate-wide food handling procedures. The Cutting Edge Program will be updated in 2020, especially with an eye to recruit more participants and independent operators as exposure to the principles of AMC increases. The FDA cooperative grant funded purchase of air time (radio) to promote the Cutting Edge Program and the idea of AMC as a management practice that the public should expect from food establishments.


The AMC Toolbox expands the reach of the AMC Class that MCESD developed for retail food operators who have repetitive risk factor violations and face potential legal action. The goal of the AMC Class is to prevent the recurrence of repetitive risk factor violations and empower operators with the tools needed to apply long-term intervention strategies. Preliminary data indicated that the 218 establishments that faced legal action in 2013-2017 averaged 2.04 Priority violations/inspection prior to the AMC class, then after attending the AMC training, averaged 0.71 Priority violations/inspection at the first post-class inspection, and 0.86 Priority violations/inspection at the fourth post-class inspection. The AMC Class attendance statistics are a very small sample and might not be representative of the population. The statistics will be updated when more post-class inspections have been conducted. At this time, repeat violations must be analyzed manually and is time-consuming. Unfortunately, the current inspection database architecture does not facilitate consecutive violation analysis.


As part of the FDA cooperative grant for the AMC Toolbox, randomized, before-and-after Risk Factor Surveys of over 600 establishments in order to obtain a baseline of violations were required. The initial survey was completed in 2016. As the end of the five-year project approaches, the second survey recently began.


The inclusion of the hyperlinks for 112 common code reference violations into the inspection reports serve to increase awareness and knowledge. Eighty-eight percent of all cited Priority violations and 85% of all cited Priority Foundation violations included a hyperlinked reference to the AMC Toolbox web app.


The AMC Toolbox project and its educational resources were presented to professionals and colleagues at eight conferences in the past four years:
- 2016 FDA Pacific Region Retail Food Seminar, Reno
- 2017 Arizona County Directors of Environmental Health Services Association Conference
- 2017 National Environmental Health Association (NEHA), Grand Rapids
- 2017 FDA Pacific Region Retail Food Seminar, Spokane
- 2018 Arizona Environmental Health Association Spring Conference
- 2018 FDA Pacific Region Retail Food Seminar, Boise
- 2018 AZDHS Annual Registered Sanitarians' Conference
- 2019 NEHA Conference, Nashville
The project was well-received and resulted in inquiries from members of several organizations.


AMC-based food inspections have been recommended by the FDA for over a decade as the best means for food establishments to reduce foodborne illness risk factors. The AMC principles of PTV are also practiced by food manufacturers and corporate franchises, and is the basis for any Hazard Analysis and Critical Control Points (HACCP). Following the principles of AMC, MCESD will continue to re-evaluate the outreach of the AMC Toolbox and the effectiveness of the AMC-based inspection program.


The web-based AMC Toolbox will require little future input and is sustainable. The education and information content of the Toolbox contains few references to technical standards that may change or become dated and require revision. The content is primarily Best Management Practices and principles that will be applicable and relevant for years. The digital files can be printed by the operators and reduce the cost of printing for MCESD. However, the professional printing of the AMC Toolbox print resources will continue for presentation of New Owner Packets” and requests for materials by operators.


In general, food establishments are serious about preventing noncompliance and protecting their reputations and business. Often, operators are reactive during inspections to correct noncompliance rather than proactive in preventing and correcting noncompliance before an inspection takes place. Demonstration that AMC can be achieved by anyone, with a little effort, should be a rewarding investment for most food managers.


MCESD maintains a highly trained EHS field staff whose primary task is regulatory inspections. The additional training of staff in AMC and continuous skills evaluation is an investment that MCESD considers worthwhile. The potential trade-offs are a more knowledgeable food industry, reduced risk of foodborne illness in the community, a more satisfied business community, and reduced legal actions.


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