To standardize a process for how routine food inspection forms are filled out, the Environmental Health (EH) staff met and developed criteria that led to the creation of a checklist to use to review inspections for consistency. Previously there was not a system developed to standardize how the forms were being filled out, so the project created an opportunity to improve the quality of reports being given to food establishments, increased standardization among inspectors, and increased food safety by providing more detailed and completed reports for the food service owners and operators. Inspections audited from February of 2013 found that 42% of inspections were in compliance when using the newly created checklist. Inspections were initially audited by the supervisors using this checklist, but to limit subjectivity the supervisors met to test their internal consistency in how the checklist was being used to review inspection reports. Based on this initial analysis, the group decided to implement the Plan-Do-Check-Act (PDCA) process.
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. The Health Data and Quality Coordinator, who is not part of the Environmental Health Section, was involved in the process for non-biased facilitation in some of the activities that took place. All team members had an active role in the discussion, design, and implementation throughout the PDCA process. From the results of the February baseline data an Aim Statement was created: By 05/13/2013, the EH Section will see an increase in the percentage of completely written inspection reports from 42% to 80%.
On 02/13/2013 the EH staff were anonymously surveyed by the Health Data and Quality Coordinator regarding how often they fill in each of the required fields on the inspection report. EH staff then each completed flowcharts to indicate their individual processes for completing inspection reports. Both tools showed variability in the procedures among the staff members.
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. This process was also facilitated by the Health Data and Quality Coordinator and management did not attend the meeting so that staff could share their thoughts and concerns to a non-biased representative. 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.
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 and management brainstormed potential solutions and created an Affinity Diagram to identify the best possible method of improvement. 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, and would be created collectively by the entire EH team.
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. 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. The supervisors also met regularly to ensure that the issue of inconsistency among supervisors was addressed, which was another concern that came out in the root causes analysis.
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. Also, individual line charts for each EH Practitioner showed weekly 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.
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. Follow up occurred with individuals who did not reach the desired mark and decreased the overall group average, whereas some individuals had 100% compliance by the end of the implementation period.
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 it is now part of the KCHD Performance Management System. When the percentage decreases in completeness on the performance management dashboard, the EH management discusses the issue and then uses quality improvement tools to determine root causes or uses quality improvement tools to identify improvement strategies to ensure the desired goals are continually reached.
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 the project has been a driving mechanism towards digital inspections in the future. The project has also lead to the creation of another PDCA in 2014 around assessing and increasing the rate of Educational In-Service inspections at food service establishments. The project was published through the Public Health Quality Improvement Exchange (PHQIX) in late 2013 and was a featured webinar on PHQIX in 2014. To share our success so that others may learn from our process, the project was presented at the Illinois Public Health Association Food Safety Symposium on September 2-4, 2014. Even though the Aim Statement of the PDCA was until 5/3/2014, the process has become standard practice and the project continues to be evaluated and address through the use of the performance management system and quality improvement methods.