The City of Newton Health and Human Services Department serves a community of 88,000 residents (80% white, 13% Asian, 4.9 % Hispanic or Latino, 3.5% Black or African American and 2.5% two or more races). Located in a suburb of Boston, Newton is the home of approximately 400 food establishments, and like many other communities, the Newton Health Department works hard to decrease foodborne illness among its residents.
The Centers for Disease Control and Prevention (CDC) estimates that one in six Americans become sick from contaminated food every year, and that reducing foodborne illness by 10% would prevent 5 million people per year from getting sick. In order to be more proactive in decreasing foodborne illness and improving food safety practices in restaurants, Newton implemented a Food Grading System to incentivize better food safety practices by restaurants.
In addition to working to decrease foodborne illness in the community by creating an incentive for restaurants to have better food safety practices, this initiative also works to increase the public's knowledge of the food safety practices at restaurants, enabling consumers to make more informed decisions about where to eat easily. Upon completion of the implementation process, Newton created a Grading System Toolkit for other communities to use as a guide to implement their own grading system based on Newton's experience. The toolkit is a comprehensive guide for other communities to create their own food grading systems and best practices to follow to support efficient implementation.
Newton's food grading system was implemented over a two-year period and included:
a pilot program (including twelve restaurants to test the inspection form and point system)
a free trial grade period (which included an unannounced inspection and a grade NOT required to post)
an announced inspection period (all restaurants received an announced inspection and were required to post the grade), and finally
an unannounced period (unannounced inspection- as consistent with prior practice- with a required grade posting at the end).
Upon receiving the grade, the inspector would require the grade to be posted in a conspicuous place in the restaurant and the grade would be inputted into a GIS map located on the City website. This way, consumers could see the grade prior to visiting the restaurant and make informed decisions about where to eat. Grades are calculated using an electronic inspection form that automatically deducts points based on the severity of the violation. The grade designations are based on a point system from 0-400 and the grade placards indicate both the number of points received out of 400 along with a word (Superior, Excellent, Acceptable, Unacceptable and Failing). The restaurants are inspected on a frequency according to their risk level and are tracked to be sure inspections are completed on time.
Data collected during the phased implementation process showed an increase in grade performance by the restaurants from the trial to the announced phases, then a slight decrease in grades from the announced to unannounced phases. The toolkit includes a brief evaluation conducted by Newton revealing that most restaurants believed that they improved their active managerial controls, and therefore implemented better food safety practices in daily business. Foodborne illness numbers are hard to measure given the underreported nature of foodborne illnesses and the variability of people eating at Newton restaurants (many do not live in Newton and therefore would not report a foodborne illness to Newton). That said, Newton hopes that its Grading Toolkit can assist other communities in implementing grading systems of their own, and thus decrease foodborne illness all over the country. Newton has created a grade placard that accurately depicts the food safety of a given restaurant and is understandable to the consumer therefore meeting the second goal of the grading system.
The factors that lead to the success of Newton's grading system were strong partnerships with stakeholders, consistent funding, strong industry and City support, community outreach, and tying the grading system in with the 9 FDA Voluntary National Retail Program Standards.
Newton hopes that communities around the US can benefit from the Grading System Toolkit that outlines Newton's experience in implementing a food grading system. The toolkit includes a step-by-step guide addressing how to best implement a grading system using lessons learned from Newton. It is the hope that many communities can use the toolkit as an effort to decrease foodborne illness in their community.
Please visit our website for more information at www.newtonma.gov/health
The City of Newton created the Grading System Toolkit in order to assist other communities in creating their own food grading system. This is the only toolkit of its kind that we know of, and its use can help cities and towns with achieving the goal of reducing foodborne illness. This innovative practice focuses on decreasing foodborne illness, a local and nationwide problem by addressing behavior change within local restaurants. As with many public health initiatives, behavior change is one of the hardest areas to address. The toolkit attempts to address the ways that a community can assist its restaurant industry in changing practices like adopting Active Managerial Controls in order to decrease the likelihood of spreading foodborne contaminants. Newton's Grading System Toolkit is a new tool to the field of public health, designed to be utilized to address the growing numbers of foodborne illness not only in Newton but in the United States.
Anyone can acquire a foodborne illness, but it is the vulnerable populations (children, pregnant women, older adults, and people with compromised immune systems) that are of the most concern in a foodborne illness outbreak. The target population of Newton's Restaurant Grading Toolkit is two-fold. It is the vulnerable populations and the large amount of Newton restaurant-goers that can acquire foodborne illness, as well as the restaurant staff in order to increase food safety compliance. The grading system encompasses over 200 restaurants in Newton, many of which are very busy all year round. It is hard to estimate the number of people reached by this program given the number of people who visit Newton restaurants from all around the Boston area.
One in six Americans become sick from contaminated food or beverages every year, and reducing foodborne illness by 10% would prevent 5 million people per year from getting sick. The CDC estimates that restaurants (specifically sit-down, dining-style restaurants) were responsible for 60% of outbreaks in 2013 (CDC's Foodborne Outbreak Surveillance System). Though there is very little research around food grading systems (since they are relatively new), the small amount of research that exists shows that food grading systems are an effective way to communicate risk to the public, increase compliance of restaurants/food establishments in food code regulation, and decrease the prevalence of foodborne illness in the United States (Simon et al., 2005). Food Grading Systems have been linked to a decrease in foodborne illness hospitalizations (Simon et al., 2005; Jin & Leslie, 2003). Data comparing foodborne disease hospitalizations five years before and three years after Los Angeles implemented a food grading system showed a 13.1% decrease in foodborne disease hospitalizations and was sustained over a two year period (Simon et. al, 2005). This data, along with support from the Newton executive office and receipt of a grant from the FDA prompted the creation of the grading system. After the grading system was implemented, many local health departments contacted Newton with questions regarding the food grading, and therefore the toolkit was created.
There are approximately 88,000 people in the City of Newton with potential to frequent the 200 restaurants that are included in the grading system. Prior to the grading system, health inspectors from the city would inspect restaurants according to their risk level, the manager or owner would receive the report and fix the problems that were cited in the report. Unfortunately, health inspectors were finding as they conducted inspections at restaurants, that many had similar problems every time they went back. This was both frustrating to the health inspectors, and foodborne illness risk factors were not being appropriately managed. A food grading system was Newton's solution to address the foodborne illness risk factors. Though violations still occur, the grading system creates higher levels of visibility and accountability in addressing foodborne illness risk factors. Because of its successful implementation with both the restaurant industry, consumer industry and cooperation with city officials, the Food Grading Toolkit was created in hopes that it could be used in other cities to share best practices of Newton's experience and for other cities to help decrease their foodborne illnesses.
The Grading Toolkit is an innovative approach to share best practices learned by Newton and to provide a step-by-step guide to best implement a food grading system. To our knowledge, there are no other food grading implementation toolkits. The design of the toolkit is very user-friendly and resource rich to assist anyone who wants to implement their own system to make it much easier. The toolkit provides procedures, forms, and guides for implementing a grading system. The toolkit is not evidence-based, however, the small amount of research done around grading systems in general supports them as good practice.
The Newton Health and Human Services Department worked to develop the food grading system and the resulting Food Grading System Toolkit with community and industry partners, businesses, city officials, state officials and our local staff. The participation of all stakeholders was pertinent to the implementation of the food grading system and its importance is highlighted throughout the Grading System Toolkit.
The restaurant owners and managers were closely consulted throughout the grading system implementation as they were to be the ones receiving the food inspection grade. Newton held multiple meetings with the industry representatives, and the local chamber of commerce to receive feedback on various aspects of the system such as: what grade placards should look like, placement of grade placards in the restaurant and many more details. Newton also worked with the Massachusetts Restaurant Association in order to address concerns they had with the food grading system. As a result of this close relationship with the restaurant industry and collaborative efforts, the Mass Restaurant Association has looked to Newton on multiple occasions to help other cities and towns in Massachusetts with their own grading system implementations because of how well planned it was. Consumers were also identified as stakeholders and were invited to participate in the meetings that Newton had with the restaurants and other industry partners.
The toolkit outlines the importance of stakeholder collaborations as a part of the â€˜step-by-step guide to implementing a grading system'. An entire section of the toolkit is designated for stakeholder identification and its importance in creating a collaboration between the local health department and the stakeholders.
The goals of the Newton grading system are as follows:
1. To increase compliance with good food safety practices in an effort to decrease the occurrence of foodborne illness in Newton
2. To provide the consumer a way to quickly and accurately evaluate the food safety practices at a certain restaurant
The goal of creating the toolkit was to provide a guide to communities in implementing their own food grading system.
There were many steps taken to achieve the goals and objectives of the Grading System Toolkit. First, funding was acquired in order to pay for staff time to write up the toolkit, pay for a graphic designer to design the toolkit, and pay for dissemination of the document. Next, a health department staff member was charged with organizing and collecting all information and data in order to write a step-by-step guide as to how best to implement a food grading system, and how Newton's experience influenced the manner in which the implementation was carried out. Then, the document was reviewed by a graphic designer, and the dissemination plan was outlined.
The Grading Implementation Guideâ€ that is the main body of the toolkit outlines 10 steps to successfully implement a food grading system in a community.
Step 1: is developing a plan to reach out to industry, community and other stakeholders. The plan should include communication methods to contact these important stakeholders.
Step 2: outlines funding sources that are available to help pay for a project such as this, and the importance of using funding and dedicating either a part-time position or a full time position to this effort in order to make it work properly.
Step 3: is stakeholder outreach and carrying forward the plan identified in Step 1. Step 4 includes updating the inspection form, updating departmental procedures for food inspections, ensuring staff are trained and updating regulations as necessary to ensure the latest food code is being used.
Step 4: outlines Newton's method of determining the establishments that were included in the grading system. Initially, hospitals, schools, nursing homes, level 1 food establishments, and grocery stores were not included in the grading system but may be added to the system in the future.
Step 5: is creating initial plans for the grading program and includes creating a grading rubric (or some tool) to use to determine the grade of a food establishment, determining what word, number or letter designation will be used on the grade placards, researching other grading systems to glean best practices, updating the inspection form, and more.
Step 6: is to start a pilot program to test the grading processes created. This includes choosing food establishments and collecting data. The data collection from this step will help communities adjust the process as necessary.
Step 7: is the trial grading process. During this process, all restaurants receive one freeâ€ inspection where they will have an unannounced inspection and will receive a grade, but they will not be required to post the grade.
Step 8: the grading system is ready to go liveâ€ and the community must pass regulations to officially make the grading system policy. Passing regulations (or however communities choose to do this) makes the grading system a formal policy or regulation, so all details and procedures will have been figured out by this point.
Step 9: marks the beginning of the announced inspection phase. This phase includes inspection staff announcing that they are coming for an inspection (within a month) and the grade, for the first time, must be posted after the inspection. After all participating restaurants are inspected, Step 10 will occur and will be the new norm.
Step 10: During this phase, inspections will be unannounced (as they were prior to the announced inspection phase) and grades must be posted.
During all steps, it is important for a staff member to be evaluating the process to ensure that all parties have had a say in how the system should work, and that the system is efficiently and accurately reporting the results of the restaurant's food safety inspection. The toolkit identifies issues that Newton dealt with, and how other communities can avoid these problems. The toolkit also puts together a list of best practices that Newton found to be effective, and suggestions that other communities can follow if they choose.
Newton's grading system took three years to implement. During this time, the health department staff worked closely with the restaurant industry to ensure friendly collaboration on the project and that all parties were well informed.
Newton received two funding sources in order to carry out activities of the grading system and writing the toolkit. The grading system was funded by the FDA (Food and Drug Administration) Cooperative Agreement. The funding was $70,000/year for 5 years in order for Newton to comply with the 9 FDA Voluntary Retail Program Standards. The strategic plan that was created as a result of the grant included the grading system as a conduit to achieve compliance with many of the standards along the way. Much of the yearly grant funded a full time Standards Coordinatorâ€ in order to achieve the goals of the grant. Other important things that were purchased using this funding included inspection software, laptops for all inspectors, and conference/training expenses. The 9 FDA Standards assist Newton's environmental health program in complying with the standards and goals of the FDA. Things such as staff standardization, procedural updates, community relations, and federal guidelines and procedures are all parts of complying with the FDA standards and all of these things fit nicely with implementing Newton's food grading system. The chart below outlines an approximation of the budget that Newton has been using to implement this program over the last 5 years.
Other Direct Costs (materials, software, conferences) $15000
Evaluation was an important piece in determining effectiveness of Newton's Food Grading System. The Food Grading Toolkit outlines the evaluation that was completed to answer the initial goals and objectives of the program:
1. To increase compliance of restaurants with their efforts to decrease foodborne illness risk factors and therefore the occurrence of foodborne illness in Newton
2. To create a tool that accurately depicts the food safety practices in a restaurant
3. To provide the consumer a way to quickly and accurately evaluate the food safety practices at local restaurants
Newton completed a brief evaluation of the grading system once all restaurants were inspected using the system at least once during the unannounced inspection period. An anonymous survey was completed by 34 establishments. The survey asked questions to determine how restaurants perceived the grading system. The survey questions are listed below:
Restaurant owners/ managers were asked to select one answer to each question and mark whether they agreed, were neutral or disagreed with the following statements:
1. The Health Department collaborated with food establishments during implementation.
2. The Health Department has provided many helpful resources throughout the grading system transition.
3. The grades accurately depict the food safety practices in my establishment.
4. Since implementation, my food establishment has adopted better food safety practices
5. My grade has affected revenue at my food establishment.
6. Each food inspector conducts inspections similarly.
The answers to these questions provided useful feedback about the grading system. First, the feedback revealed that Newton's health department did a good job in both collaborating with (88% agreed) and providing useful information throughout implementation of the grading system (82% agreed). The next question in the survey asked if the grades accurately depicted food safety practices in each establishment. 65% of respondents agreed, and 93% either agreed or were neutral to this question indicating that most people think that the grading system functions as a good tool to appropriately determine the efficacy of an establishment's food safety practices. Many establishments agree (70%) that they have improved food safety practices and very few (3%) think the system affects the revenue of their establishment. The final point the survey addresses is whether each inspector conducts inspections similarly. 84% either agree or were neutral to the statement that each inspector conducts inspections similarly.
Newton also analyzed data mid-way through the implementation process. The data that was collected compared grades from the trialâ€ phase (unannounced inspections, no grade posting required), to the announced phase (announced inspections, required grade posting). This data showed an increase in the number of restaurants that received a grade equivalent to a B or better from 75% to 96%. It showed a decrease in the number of restaurants receiving a C or below from 48% to 3.6%. The Unannounced grades have shown a slight decrease in the average grade (most likely since inspections are unannounced) with most restaurants receiving a B average or better.
Newton effectively collaborated with and provided useful resources to restaurants throughout implementation of the grading system. Newton worked very hard to remain transparent during the process and seemed to achieve this goal as perceived by restaurant owners/managers. Question 3 asks the respondents if they thought the system accurately depicted the food safety practices in their establishment. Many cities and towns grapple with how to make a system that is both fair to the food establishment, and holds them accountable for poor food safety. Newton worked for years to create the final version of the current grading tool, and many people (65%) agreed that it was a good tool. This 65%, though seemingly low, is a positive for Newton, considering the time and effort the tool took to create, and the knowledge that not every food establishment manager/owner was pleased about Newton adopting a grading system to begin with.
The next question asks if the food establishment has adopted better food safety practices since implementation. Approximately 70% agreed that their food establishments improved food safety practices. From the outset of the grading system, Newton had a goal to use the grading system as an incentive for food establishments to improve their food safety practices. This data shows that most restaurants are at least trying to improve their food safety practices which is a win for Newton (and the consumers in Newton). The next point comments on the revenue of the food establishment being affected by the grade. Only 9% (or 3) respondents indicated that the grade affected their overall revenue (the question does not ask whether the revenue increased or decreased). Initially, this was one of the main concerns brought forth by the food establishment representatives, and a seemingly common myth, that revenue would be affected by grades. Most respondents in this survey answered that their grades have not affected revenue.
Finally, the last question asks about inspections and whether inspections are conducted similarly by each inspector. About half of respondents agreed that inspections are conducted similarly (no matter which inspector is doing them). 35% were neutral on this question and 16% disagreed. This question brings up a topic that has been discussed frequently in the food safety community and is specifically addressed in Standard 2 of the FDA Retail Program Standards. Compliance with Standard 2 attempts to ensure that every inspector in the department is standardized according to FDA guidelines and through standardization, will conduct an inspection the same as the next standardized inspector. Newton has two standardized inspectors out of the four, and is working to complete standardization of all of its inspectors. Even with standardization, differences will occur between inspectors. It is therefore, not surprising that food establishments think that inspectors conduct inspections differently.
Finally, the evaluation answered two of the three goals set out for the program:
To create a tool that accurately depicts the food safety practices in a restaurant
To provide the consumer a way to quickly and accurately evaluate the food safety practices at a certain restaurant
The final goal of determining the use of the toolkit to other communities has yet to be determined as the dissemination of the toolkit has not occurred as of the date of this summary.
The results of this data did not cause any changes to our current practice. That said, during the implementation process we experienced many lessons learned that may cause slight changes to the program in the future including: incorporating hospitals, schools, level 1 establishments, and nursing homes in the system, altering the grade placard slightly, and other small procedural changes regarding grade pick-up.
The lessons learned from Newton's Food Grading System implementation included the importance of stakeholder collaboration. The restaurant industry members were very concerned about the grading system from the start. They had many questions and comments throughout the process and were included in the conversation the whole time. Newton made sure to hear them out and take them up on many ideas about different aspects of the system. Although the discussions were somewhat contentious at times, in the end, the restaurants really appreciated the effort the city put forth to include them in the process. Another lesson learned was that implementing a grading system required lots of time. Initially, the timeframe to complete the project was about a year including a pilot program followed immediately by requiring grade posting. Newton found that this process was not that easy. There were many major changes that had to happen to the inspection form design before grading could begin. Newton also decided that all restaurants should have a trial grade before being required to post grades. These factors, along with writing the regulation took much longer than expected. The additional year it took to implement turned out to work in favor of both the restaurants and the city as both had ample time to work out the kinks of the grading system.
The grading system is a self-sustaining entity. The initial manpower it took to create the procedures and placard, reach out to all stakeholders, design and properly test a new inspection form, purchase inspection software etc., were all one-time actions. The activities of the grading system are all carried out by the inspectors. They complete inspection reports and are able to print the grade placard immediately. They have the computer program to be able to analyze the grade data taken from the inspections and create monthly inspection schedules to remain on track. As for the cost of the program, the only cost that remains consistent is the yearly electronic inspection form and that can likely be picked up by the city once the grant runs out.
A cost-benefit analysis was not completed due to the relatively low year-to-year cost of certain aspects of the program.
The health department will continue its practice of grading food establishments based on the inspection reports. The Mayor of Newton, Commissioner of Health and Human Services and Newton inspectors are dedicated to continue the grading system and are hopeful that it continues to improve the food safety practices of restaurants and helps to lower the foodborne illnesses in Newton.
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