Our environmental health services receive great scrutiny as far as number of services delivered goes, but little has been done to assess and improve the quality of these services. As a district health department we inspect nearly a thousand local food service establishments each year. This service reaches a huge number of community members, both as owners, workers, and as patrons of these establishments. The health department's relationship with these food establishments has a major impact on the health of our community, as a positive rapport with the environmental branch increases the likelihood that they will see environmentalists as a resource and readily take suggestions to improve the safety of food service delivery and act as partners in reporting potential food-borne illnesses. It was perceived that the relationship between environmentalist and restaurant was viewed as solely regulatory, so we aimed to understand perceptions through survey questions, enabling our health department to better reframe the relationship as collaborative and between community partners for the sake of public health.
A large-scale customer satisfaction initiative was undertaken with the goal of improving restaurant inspection scores and reducing numbers of food borne illnesses through improving the relationship between environmentalists and those they inspect, several outcomes were identified:
- Assess relationships between the restaurants inspected and environmental health staff who conduct inspections
- Examine what value food service establishments see in inspections and related services
- Identify areas that are strengths and celebrate with our often unrecognized environmental staff
- Identify weak areas and develop a plan to improve on these
Barren River District Health Department
Environmentalists as Partners: Customer Satisfaction with Restaurant Inspections
Barren River District Health Department is situated in South Central Kentucky, serving 257,171 people in eight rural counties. Barren, Butler, Edmonson, Hart, Logan, Metcalfe, and Simpson surround Warren County, which is home to 44% of service area residents. About 60,000 Warren County residents live in Bowling Green, which is the area’s population, commercial, employment and educational center. Our regional population is predominantly white, with 9% as Black, and 1% as Asian, or Other. Another 3.4% are Hispanic. The population includes a significant number of foreign born residents of all races and ethnicities, including 8,401 foreign born residents in Warren County alone. About 1/3 of them are Hispanic immigrants working in agriculture, manufacturing, and service industries. Approximately 20% are here with WKU and/or industries owned by foreign corporations. Many foreign born Bowling Green residents resettled as refugees from African, Southeast Asian and Eastern European countries.Barren River District Health Department's Environmental Health Branch inspects over 900 food service establishments in the eight county area, playing a major role in food safety and so impacting the health of every person who dines in these facilities, making restaurant inspections one of the most wide-reaching services provided by the health department. Through a tracking system the environmentalists track and monitor compliance to the inspection schedule, assessing whether there are issues in completing inspections on schedule. However, no measures of quality or explorations for improvement have ever been conducted for this branch, resulting in the decision to implement customer satisfaction surveys regarding inspections for all food service establishment inspections.
With the larger goal of improving restaurant inspection scores and reducing numbers of foodborne illnesses through improving the relationship between environmentalists and those they inspect, several outcomes were identified:
Assess relationships between the restaurants inspected and environmental health staff who conduct inspections
Examine what value food service establishments see in inspections and related services
Identify areas that are strengths and celebrate with our often unrecognized environmental staff
Identify weak areas and develop a plan to improve on these
To measure these areas and determine a course of action, an initial customer satisfaction survey was sent to all food service establishment inspections. This includes restaurants and other facilities that serve food, such as convenience stores that sell ready-to-eat food, and totals over 900 facilities in Barren River District Health Department's eight-county service area. The survey included questions to assess how food service establishments view the environmentalists, whether they believe the environmentalists are knowledgeable, and whether services were satisfactory. Open-ended questions ascertaining what was helpful and what needed to be improved on where also included. This survey and subsequent analysis allowed us to understand and make needed decisions to achieve all of the bulleted objectives above, though with all of our quality improvement practices, we view the project as ongoing.
This practice of using a customer satisfaction survey to identify areas for improvement and better the trust relationship between inspectors and the inspected has been highly valued by our staff. Receiving recognition through the overall positive customer feedback has been invigorating internally. The areas identified to improve on were well-received and staff at all levels have been happy to adopt the suggestions the Performance Management Coordinator and Environmental Health Director came up with. Customer satisfaction with food service establishment inspections is ongoing and further changes will be made as new issues are identified. Over the next three years, we anticipate seeing the average food service establishment inspection score rise, indicating that these establishments are safer as the result of the EHB staffs ability to better serve these businesses.
Statement of the ProblemRestaurants and other food service establishments are potentially excellent partners for public health departments. These entities play an important role in food safety of the population, through using best practices for food safety at all times and through collaborating with the health department to help identify possible food-borne illnesses. Food safety has been identified as a winnable battle by the CDC and so partners that contribute to this goal are especially valued. With concern that food service establishments might view establishment inspections as something to be feared or environmental staff as antagonists, it was important to understand how restaurants and other food establishments perceived environmentalists and what areas could be improved on, so that the health department was a resource and a partner rather than a punitive organization for most establishments.Target Population
Approximately 910 distinct food service establishments, who in turn serve the entire population of 257,000+ people in the eight counties, plus all other patrons who frequent the area for events at Western Kentucky University, the Corvette factory and museum, Mammoth Cave National Park, and other travelers.20% of food service establishments (183) submitted completed surveys by the due date.
Past PracticesNo quality or customer satisfaction data has been collected for food service establishments at BRDHD, to the best knowledge of the current branch supervisor.Current PracticeThe current practice of assessing opportunities for quality improvement through customer satisfaction data is an improvement over doing nothing to formally view these areas. Moving from simply determining compliance as it relates to public health services to studying these areas for potential quality improvement is an exciting shift happening at BRDHD and at health departments across the nation, thanks in part to the importance of performance management and quality improvement practices emphasized by the Public Health Accreditation process.
Innovativeness of PracticeThis is an innovative use of existing customer satisfaction practices. BRDHD has emphasized customer satisfaction in the agency Strategic Plan and has relied heavily on the King County Customer Satisfaction Guide included in NACCHO's Toolbox to guide practices. Our use of customer satisfaction as a way to build partnerships specifically in an arena of public health that is often viewed only in terms of compliance to standards, and so to improve the quality of these services and create a stronger relationship, is innovative. The Public Health Accreditation Board singled out this customer satisfaction practice in review of Domain 9.1.3, commending it as well-planned and providing useful information and analysis.
Goals and Objectives
Assess relationships between the restaurants inspected and environmental health staff who conduct inspectionsExamine what value food service establishments see in inspections and related servicesIdentify areas that are strengths and celebrate with our often unrecognized environmental staffIdentify weak areas and develop a plan to improve on these
Steps Taken to Implement Program
Questions were developed to determine how environmental health staff and the inspections they administer to food service establishments are viewed by those establishments. These surveys were mailed out to the 900+ food service establishments currently inspected by BRDHD, along with a stamped and addressed return envelope. The results were entered into Survey Monkey via a collector link and data was reviewed. After finding that responses to the five quantitative measurement quality questions were largely positive, careful examination of comments was conducted. Comments were categorized by theme, then suggestions for what to be done about each identified theme issue were reviewed and a course of action was determined.
Recipients of Practice
Going by the criteria of what programs didn't have any sort of qualitative improvement or customer satisfaction data available, many programs at our health department would qualify. We chose to focus on the Environmental Health Branch because they historically have only received compliance-based review at our health department, and because they are important ambassadors for the health department, coming into contact with many community partners and in turn providing services that insure the safety of the population at large.
The customer satisfaction survey was implemented in April of 2014 and all results were analyzed, suggestions made, and a course of action decided on by August 2014. Use of results and continued efforts to improve the quality of environmental health inspection services is on-going.
Our primary community stakeholders for this project were the individuals being given the customer satisfaction surveys. Food service establishments are important partners to larger community health.
The Environmental Health Branch incurred costs of $873.60 in postage for this project alone. Roughly $51.30 (purchasing department estimate) was spent on envelopes, and the cost of printing addresses and surveys is estimated at $63.37. The staff time that went into developing the survey, preparing materials to mail, entering data, and analyzing data was enormous. No cost center was designated for this project and so no accurate measures of staff time are available. For a money-strapped and staff time-poor health department, this was a costly endeavor.
The primary data source has been the survey sent out. Survey results were transcribed from paper to a Survey Monkey data collector by BRDHD office support staff, spot-checked by the Performance Management Coordinator to insure data quality.
The EHB and the Performance Management Coordinator developed a survey instrument to gauge customer satisfaction with the environmental health services rendered to food facilities and to elicit comments and/or suggestions on how to improve the activities related to insuring safety of local food service establishments.
The surveys were mailed out, along with a letter explaining the purpose of the survey and a stamped and pre-addressed envelope to facilitate the food facility returning the survey. A schedule of upcoming food manager certification classes was also included. “Food facilities” in this case was defined as a food service establishment (such as restaurants, convenience stores, child care facilities, or schools) in which food evaluations are performed by the EHB.
Approximately 910 survey forms were distributed with stamped return envelopes. This represents about 90% of the district’s approximate 1000 permitted food establishments. Incorrect mailing addresses prevented distribution to 10% of permitted facilities. Survey recipients were asked to fill out the survey and mail it back anonymously. 183 survey forms were returned for a return rate of approximately 20% of potential respondents, an excellent response rate, especially considering the additional step of mailing took for the respondents to return the survey.
Three questions were asked to better understand the clients who answered, including what type of establishment they were responding for, what forms of contact they had with the EHB, and what services they received from the EHB other than the Food Manager Certification classes.
Beyond the questions that assess business type and what services respondents had received, there were three open-ended and five rated questions. The information from the rated questions ask specific questions about satisfaction with the EHB staff and services.
SATISFACTION WITH EHB STAFF and SERVICES
The five questions asked of food service establishment owners and managers to determine basic satisfaction with staff and services all had overwhelmingly favorable feedback, indicating that these customers are overall very pleased with the quality of services offered.
Were you treated fairly and with respect?
Survey respondents overwhelmingly (99.5%) felt they were treated fairly and with respect by the environmentalists.
Were the Environmental Health staff knowledgeable?
Food service establishments overwhelmingly see our health staff as knowledgeable, with 93% indicating they are always knowledgeable and none responding “Sometimes” or “Never.”
Were the Environmental Health services provided in a timely way?
The services provided by the EHB were found to be timely for most respondents. 84% felt services were always timely, 14% felt they were usually timely, 2% said sometimes, and no respondents said never.
How satisfied were you with how well things were explained to you by the Environmental Health staff?
Customers were overall satisfied with how well requirements and questions were explained to them by the EHB staff (97.8%), demonstrating that EHB staff do an exemplary job of communicating information to the owners and managers of community food service establishments.
Overall, how satisfied were you with the Environmental Health services you received?
The Environmental Health Branch clients who responded to the survey overwhelmingly were satisfied with the services provided by the EHB staff, with only 2.8% dissatisfied.
Three open-ended questions were asked of survey respondents, giving customers the opportunity to elaborate on what they would like to see change. Again, overwhelmingly the responses were positive. When these comments were shared with EHB staff they responded positively and appreciated seeing that community members appreciated the services they offered.
What was most helpful about the services provided to you by our Environmental Health staff?
93 respondents answered the open-ended question, “What was the most helpful about the services provided to you by the Environmental Health Branch?”
One person responded “none”, but the rest of the respondent’s answers were positive, so that comment has been interpreted to mean that there are not any services sticking out in that respondent’s mind as being especially helpful.
The other 92 comments were very positive. Areas highlighted by these positive comments were the ability of the EHB staff to keep food service establishments up to date on any new regulations, ready to review existing regulations, the perception that EHB staff do not just list what is wrong but help establishments figures out how to correct the issue, and general willingness to share information and materials. Comments also reveal that EHB food service clients appreciate the professional and friendly attitude of the environmental staff and look forward to opportunities to speak with the staff and continue learning.
Do you have any suggestions about how to improve our Environmental Health services?
55 respondents answered the question “Do you have any suggestions about how to improve our Environmental Health Services?
14 of those were suggestions or critical. The other 41 comments were that respondents did not have any specific suggestions, some taking the time to add specific praise.
42 respondents had additional comments. 32 of those were explicitly positive, 6 were critical, 1 was negative, 4 were neutral suggestions, and 1 was a “not applicable.”
THEMES OF SUGGESTIONS
There were seven comments suggesting that clients would like inspections to be more regular and for inspections or other services to happen more often. The comments indicate that the services provided by the EHB staff are valued by food service establishment owners and they would like to see more of the environmentalists. There was also one comment indicating that understaffing resulting in delayed inspections might cause issues for those restaurants with other overseeing entities.
Follow up on complaints
Two different respondents identified that they had brought what they saw as an issue of other business operating inappropriately to the attention of environmentalists and didn’t have any follow through.
There were two comments specifically requesting changes to the BRDHD website for functionality, one comment indicating they did not know who to contact with a question or concern and this information needs to be more clearly publicized, and one comment indicating that the customer was unhappy with the interpersonal skills of a BRDHD environmentalist.
Clear communication of expectations
There were seven comments that indicated that customers felt the expectations had not been clearly communicated or were not applied consistently.
BRDHD’s Environmental Health Branch is chronically understaffed as the result of budget cuts. During this survey an environmentalist left for another job and his position was not filled and there is no plan to fill it, despite no reduction in community demand for services provided by the EHB.
At this time, there is nothing that can be done to directly address understaffing issues due to budget cuts. Environmental staff will continue addressing client need as quickly as possible and will continue to strive to stick to the food service establishment inspection schedule as closely as possible.
Follow up on complaints
To address complaints made by community members a form letter has been implemented. EHB staff do report they have always followed up on every concern or complaint made, but there was no opportunity for the person who brought up the issue to know it has been followed up on. When a complaint is called or emailed in, the individual making the complaint are now told that they can leave their contact information if they would like to know when the issue has been followed up on by EHB staff. If the person leaves contact information, they will receive a form letter reading “The issue you called/ emailed/ wrote about on DATE has been looked into by one of Barren River District Health Department’s Environmental Health Branch staff. We have taken appropriate action for the matter.” This lets the community member know their concern has not been ignored while not sharing any specific information.
The need for added communication for the Environmental Health Branch has been noted and will be explored and addressed by the CDC Public Health Associate assigned to BRDHD since October 2014, who is addressing website improvements as part of her work plan.
The issue of staff needing to work on their interpersonal skills was addressed in a staff meeting, as there was one comment that indicated this was an issue. The overall responses to “Were your treated fairly and with respect” addressed in Table 4 indicate that this is not a pervasive issue.
Clear communication of expectations
Publicizing and making deadlines, guidelines, and requirements more available to food service establishment owners and managers has been added as a need as the CDC Public Health Associate assists BRDHD in updating the agency website.
Once recommendations were addressed results and the changes based on these results was disseminated to all BRDHD staff, those who answered the survey, uploaded to the BRDHD website, and generally put up for display throughout the eight Barren River District county health departments to share information on the results and what the response is.
Given the expense (in postage and in staff time) of conducting a survey this large, we do not plan to conduct another full survey of this exact population for another 3 years unless an issue or change is detected. Instead, we will follow up with short questionnaires to be handed out by environmental staff when making visits to the food service establishment owners and managers. These short surveys will not prioritize asking everyone but instead asking a representative sample and will focus questions that assess the impact of changes made based on the results of this report, following the PDSA cycle, to see if changes are achieving the desired results.
In general, the responses from both the five ranked questions and the three open-ended questions indicate that these customers are overwhelmingly happy with and appreciative of the services provided to them by BRDHD’s EHB staff. Environmental staff appreciated seeing the results and comments and reported in a staff meeting that it made them feel more positive about their jobs to see that the services they provided were not unnoticed and that they were not seen only as enforcers of the law. Knowing that their customer appreciated them and even wished for more contact is morale-boosting.
Baseline Food Inspection Scores: April 2013 - April 2014
Type of Inspection Count Average ScoreComplaint 148 93.6Enforcement action 1 n/aFollowup 192 96.8Other 32 95.2Regular 1377 96.7Grand Total 1750 96.7
These scores will be assessed anually as modifications are implemented and customer satisfaction results are analyzed in an on-going way.
By necessity, food service establishments still largely need to be contacted by mail. Electronic surveys are impossible to send out for many establishments. However, mailing out on a large scale regularly is not fiscally feasible for our agency, nor is it deemed a good judge of time. Starting in November 2014, further customer satisfaction surveys are distributed to 1/20 food service establishments inspected. The hand delivery cuts down on costs, though a stamped and addressed envelope is still provided for the business to anonymously mail in their surveys. The results will be entered into a database as they come in and analyzed every 6 months by the Performance Management Coordinator and the EHB Director, unless a "red flag" comment is noted on an incoming survey, in which case they will meet as soon as possible to discuss and address.The internal stakeholders (the Environmental Health Branch staff) found the practice to be enlightening and look forward to more opportunities to learn what their customers think of them, what they can do to foster better community partnerships, and what the long-term quantitative results will be. The restaurants and other establishments inspected had positive feedback about the process and we are optimistic about their continued cooperation with data collection efforts, and candor in identifying what can be done to improve the services BRDHD EHB staff offer to them, and as a result to the community at large.