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Memphis and Shelby County Health Department
(MSCHD) is a joint funded agency of County and
City governments. Shelby County contains seven
incorporated municipalities (e.g., Memphis,
Arlington, Bartlett, Collierville, Germantown,
Lakeland, and Millington) and several
unincorporated areas. Shelby County is also the
largest county in the State of Tennessee, both
geographically (approximately 783 square miles)
and in population (909,035). With over 5,000
food establishments throughout Memphis and Shelby
County, MSCHD is required by both Tennessee
Department of Health and Tennessee Department of
Agriculture annotated law to inspect facilities
twice per year, and more often if critical
sanitation violations have been cited or if there
are food-borne outbreaks or food-borne complaint
investigations.
Implementation of a Pilot Program to Address
Reliability of Environmental Sanitation
Inspections at Memphis and Shelby County Health
Department Tyler Zerwekh, DrPH Memphis and Shelby
County Health Department Environmental Health
Bureau
LOGO
LOGO
MATERIALS AND METHODS
RESULTS
BACKGROUND
Program Goal To implement an environmental
sanitation inspection pilot program to address
reliability, validity, and repeatability results
for a comprehensive environmental sanitation
program. Health Problem More than 54 billion
meals are served at 844,000 commercial food
establishments in the United States each year and
nearly half of all money spent on food is done so
at food establishments. On a typical day, 44 of
adults in the United States eat at a restaurant.
Approximately 40 of food-borne disease outbreaks
reported to the Centers for Disease Control and
Prevention are attributed to commercial food
establishments. Preventing restaurant-associated
food-borne disease outbreaks is an important task
of public health departments. Many times,
sanitation inspections performed by public health
departments at these food establishments are not
efficient or reliable when performed due to
myriad reasons including, but not limited to,
inspector training level, workload, and type of
facility inspected. Outcome Objective The Memphis
and Shelby County Health Department Environmental
Sanitation program aimed to work with program
managers, lead environmentalists, and
environmentalist to implement and execute a
quality assurance pilot project that would
increase the repeatability and accuracy of
environmental sanitation inspection scores at
sanitation facilities. Determinant Tennessee
Department of Health program audit determined a
difference in 35 points (5 violations, 1 critical
violation) on average of facilities audited after
a MSCHD Environmentalist inspection METHODOLOGY
  Event Quality Assurance Pilot Program
Planning Activities Meeting with Environmental
Health Administrator and MSCHD Director of Health
to present ideas for increasing repeatability and
accuracy of sanitation inspections (June
2008) Meeting with MSCHD Environmental Sanitation
program managers to unveil quality assurance
pilot program sanitation inspection audit process
and enlist support for the program (August
2008) Develop a timeline for integration,
implementation, and execution of the pilot
program (August 2008)   Event Workforce
Development and Enhancements Addressing
personnel issues and the increase in expertise
through workforce development and
technology Activities Assess TDH audit criteria
into pilot program training to ensure
standardization (August 2008) Conduct trainings
for Lead Environmentalists to standardize audit
inspections (September 2008) Conduct
trainings/re-trainings for Environmentalist to
standardize sanitation inspections (September
2008) Reassign inspection zones to minimize
inspection bias and confounding   Event Pilot
Program Implementation Activities Environmentalis
ts inspection of facilities Lead
Environmentalists audit inspections of random
facilities. Education to operators selected for
audit inspections of pilot program Environmental
Sanitation program manager analysis of audit
inspections

• With over 5,000 food establishments throughout
  Memphis and Shelby County, MSCHD is required by
  both Tennessee Department of Health and Tennessee
  Department of Agriculture annotated law to
  inspect facilities twice per year, and more often
  if critical sanitation violations have been cited
  or if there are food-borne outbreaks or
  food-borne complaint investigations.
• The association between environmental sanitation
  inspections and food-borne outbreaks in
  communities has been documented extensively.
  With only seventeen environmentalists trained at
  MSCHD to perform sanitation inspections on the
  5,000 facilities, it is not uncommon for an
  environmentalist at MSCHD to perform over 700
  inspections and follow-ups in one calendar year.
  The sheer amount of inspections by
  environmentalists can lead to practices that
  ultimately compromise the integrity of an
  individual inspection to satisfy the overall
  arching goal of total inspection completion.
• During a recent audit investigation by the
  Tennessee Department of Health (TDH) on the MSCHD
  Environmental Sanitation division, it was
  documented that unannounced inspections by TDH
  immediately after a MSCHD inspection yielded an
  average difference score of 35 points with a
  range of one to five critical violations not
  documented by MSCHD environmentalists but
  observed and documented by TDH audit staff.

• A total of 36 facilities were audited for 16
  Environmentalists by 3 Lead Environmentalists
  during the month of December 2008.
• Results demonstrated an average of 6.11 points
  lower score when the Lead Environmentalist
  performed an audit inspection after the
  environmentalist.
• The range of difference in sanitation inspection
  was from 20 points lower to 9 points higher than
  the Environmentalist when the Lead
  Environmentalist performed the audit inspection
  immediately after the initial

PURPOSE AND HYPOTHESIS
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• The significance of these findings listed in the
  Background has immediate environmental public
  health ramifications on Shelby County, TN, and
  its stakeholders. Inaccurate and underscored
  inspections increase the likelihood for a
  facility to continue practices and controls
  deemed unsanitary and unsafe. This can lead to
  an increased risk in unsafe food and food
  handlers, which ultimately leads to a higher
  probability of food-borne and infectious disease
  transmission to facility patrons. This project
  will focus on the development and implementation
  of a sanitation pilot program that aims to
  increase the accuracy and reliability of
  environmental sanitation inspections within the
  MSCHD Environmental Sanitation Section.
• Problem Statement Implementation of an
  environmental sanitation inspection pilot program
  to address reliability, validity, and
  repeatability results for a comprehensive
  environmental sanitation program, which will
  provide accurate and representative sanitation
  scores of operator facilities to Shelby County
  stakeholders.

CONCLUSIONS
The results demonstrate the pilot program was
unsuccessful upon initial examination. However,
it is worth noting that 20 (7 / 36) of the
facilities audited did observe the
environmentalist scoring the facility lower than
the audit procedure done by the Lead
Environmentalist after the initial inspection.
These results extrapolated demonstrate there was
value in implementation of the program, whether
it was due to fear/concern the environmentalist
would be exposed for poor inspection methodology
or because there was an actual observed
improvement in the sanitation inspection
procedure.   While the results were not
favorable, it is worth noting this was the
initial audit follow-up analysis for this pilot
program and hopefully future audits will
demonstrate more frequent and improved
reliability and repeatability in
environmentalists scores and Lead
Environmentalists audits. Future steps and next
directions include 1) continued audit
inspections to further underscore the importance
of proper sanitation inspections, 2) refresher
and additional trainings for environmentalists
who continue score inspections higher than audit
follow-ups, and 3) disciplinary action for
environmentalists who continue to underscore
sanitation inspections.  
BIBLIOGRAPHY
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For more information, contact Tyler Zerwekh,
DrPH Memphis and Shelby County Health department
814 Jefferson Ave., 502H Memphis, TN
38105 Email Tyler.Zerwekh_at_shelbycountytn.gov