RESEARCH Current Research Continuing Education Questionnaire, page 307 Meets learning need codes 8000, 8010, and 8040 Readiness to Implement Hazard Analysis and Critical Control Point (HACCP) Systems in Iowa Schools DANIEL HENROID, JR, MS, RD; JEANNIE SNEED, PhD, RD ABSTRACT Objective To evaluate current food-handling practices, food safety prerequisite programs, and employee knowledge and food safety attitudes and provide baseline data for implementing Hazard Analysis and Critical Control Point (HACCP) systems in school foodservice. Design One member of the research team visited each school to observe food-handling practices and assess prerequisite programs using a structured observation form. A questionnaire was used to determine employees’ attitudes, knowledge, and demographic information. Subjects/Setting A convenience sample of 40 Iowa schools was recruited with input from the Iowa Department of Education. Statistical Analyses Descriptive statistics were used to summarize data. One-way analysis of variance was used to assess differences in attitudes and food safety knowledge among managers, cooks, and other foodservice employees. Multiple linear regression assessed the relationship between manager and school district demographics and the food safety practice score. Results Proper food-handling practices were not being followed in many schools and prerequisite food safety programs for HACCP were found to be inadequate for many school foodservice operations. School foodservice employees were found to have a significant amount of food safety knowledge (15.9⫾2.4 out of 20 possible points). School districts with managers (P⫽.019) and employees (P⫽.030) who had a food handler certificate were found to have higher food safety practice scores. Applications/Conclusions Emphasis on implementing prerequisite programs in preparation for HACCP is needed in school foodservice. Training programs, both basic food safety such as ServSafe威 and HACCP, will support improvement of food-handling practices and implementation of prerequisite programs and HACCP. J Am Diet Assoc. 2004;104:180-185. D. Henroid is an extension specialist and J. Sneed is a professor with Iowa State University Hotel, Restaurant, and Institution Management, Ames, IA. Address correspondence to: Daniel Henroid, Jr, MS, RD, Iowa State University, Hotel, Restaurant, and Institution Management, 9e MacKay Hall, Ames, IA 500111120. E-mail: dhenroid@iastate.edu Copyright © 2004 by the American Dietetic Association. 0002-8223/04/10402-0004$30.00/0 doi: 10.1016/j.jada.2003.11.009 180 Journal of THE AMERICAN DIETETIC ASSOCIATION F oodborne illness is a concern for vulnerable groups such as infants and young children, elderly individuals, and those with compromised immune systems (1). For foodservice operations serving these groups, ensuring food safety is critical. The federal government emphasizes food safety through efforts such as the National Food Safety Initiative. The Centers for Disease Control and Prevention (CDC) estimates that foodborne illness causes “approximately 76 million illnesses, 325,000 hospitalizations, and 5,000 deaths each year in the United States. Unknown pathogens account for approximately 62 million illnesses, 265,000 hospitalizations, and 3,200 deaths” (2). The important role of food safety is well established (3), © 2004 by the American Dietetic Association and food safety issues have been documented in school foodservice. The General Accounting Office (GAO) reported 20 outbreaks of foodborne illness in schools in 1997 (4), only eight of which were associated with food prepared on school premises. A recent GAO report (5) indicates that the number of foodborne illness outbreaks has increased in schools by approximately 10% per year since the early 1990s; however, the number of outbreaks can be accounted for partially by new data collection procedures initiated by the CDC in 1998. Unfortunately, there is no method to determine which outbreaks attributed to schools were caused by foods prepared in schools compared with food that was brought into schools by students. School foodservice programs served more than 38.1 million children in 2002, and approximately 6.1 billion meals (6). During 2002, 380,099 children were served in Iowa (7) and they received more than 63 million meals from the National School Lunch Program alone (8). Thus, the potential impact of improving food safety practices and implementing Hazard Analysis and Critical Control Point (HACCP) systems in school foodservice operations could be significant. Little research has documented the readiness of schools for implementing HACCP. The purpose of this research was to evaluate current food-handling practices, presence of prerequisite food safety programs, and employee knowledge and food safety attitudes in Iowa school foodservice operations, and to provide baseline data for implementing HACCP in school foodservice. Prerequisite programs, including good manufacturing practices, address operational conditions and provide the foundation for the HACCP system. These programs include areas such as supplier control, temperature monitoring, personal hygiene standards, and pest control, and often are addressed through sanitation standard operating procedures. METHODS Subjects A convenience sample of 40 schools from 40 different school districts was selected from the state of Iowa for the study. Participants were selected on the basis of the recommendations from the staff from the Iowa Department of Education and the Iowa State University Extension nutrition and health field specialists. School foodservice directors were contacted and asked to participate in the study. Directors were informed of the scope of the study, benefits of participation, and confidentiality of data. School foodservice directors who agreed to participate were asked to select one school within the district to be included in the study. It was requested that the selected school be a production kitchen, not a satellite operation. Random identification codes were used for identifying schools throughout the study to maintain confidentiality. The Iowa State University Institutional Review Board approved the study. Survey Instruments Baseline assessments of schools consisted of three components: an on-site visit, an interview with the school foodservice manager, and a test of employee knowledge and attitudes about food safety. An on-site assessment form was developed based on the Iowa inspection form and previous research conducted by Giampaoli et al (9). All three research team members conducting assessments were trained to use the form. Before conducting the assessments, the research team visited two schools to pilot test the assessment form and process. Each researcher conducted independent assessments of the foodservice production facility and employee food-handling practices. Results were compared and discussed after each assessment to establish inter-rater reliability. The assessment form was modified after each pilot test. Data Collection Assessments of the 40 school foodservice operations were conducted over 2.5 months. Each three-hour assessment included observations of food preparation and service. Informal interviews with school foodservice employees were conducted to determine the extent of food safety knowledge and food-handling practices. In addition to observations, objective measurements such as food temperatures, temperatures of refrigerators and freezers, dish machine temperatures, and chemical sanitizer concentrations were done using recommended procedures. Food temperatures were checked with calibrated, tip-sensitive digital thermometers (Taylor, Model 9840, Oakbrook, IL). Thermal strips (Paper Thermometer Co., Inc., Greenfield, NH) were used to check high-temperature dish machines and test strips (Blue Ridge Test Papers, Purchellville, VA; Micro Essential Laboratory, Brooklyn, NY) were used to check sanitizer concentration in low-temperature dish machines and pot-and-pan sinks. Measurements were compared with standards in the State of Iowa Food Code to determine compliance. The written employee questionnaire was developed to determine knowledge and attitudes about food safety. Twenty knowledge questions and six attitude questions were included. The questionnaire was reviewed by content specialists and pilot tested by students enrolled in a university sophomore-level food safety and sanitation course on the first day of class. An item analysis was conducted on the pilot test results. The knowledge test had a Kuder-Richardson 20 (KR-20) reliability coefficient of 0.65. As a result of the item analysis, several test questions were modified to improve clarity. At the time of the assessment, school foodservice managers were given employee tests and an addressed, postage-paid envelope. Each test was numbered with a threedigit code to identify the school and a test number. School foodservice managers distributed the employee tests. Each employee was asked to sign a separate sheet to indicate the test number they received. After completion, the school foodservice director mailed the employee tests to the research team. Researchers were not able to administer the tests because of time limitations and employee work schedules. Data Analysis All statistical analyses were conducted using SPSS for Windows (version 11.0, 2001, Chicago, IL). Statistical significance at Pⱕ.05 was used for all tests. Before data analysis, responses to food safety attitude statements were converted to numeric values: strongly disagree⫽1, disagree⫽2, neutral⫽3, agree⫽4, and strongly agree⫽5. Missing values for food safety attitude statements were treated as “no opinion” and were assigned a neutral value. Means, standard deviations, and frequencies were computed for all variables. One-way analysis of variance was Journal of THE AMERICAN DIETETIC ASSOCIATION 181 Table 1. Characteristics of participating school foodservice operations (N⫽40) Table 2. Demographic characteristics of school foodservice managers (N⫽40) MeanⴞSDa District characteristics Number of schools in district Students in district Study school characteristics Number of students Total number of employees Managers/supervisors Cooks Other Total number of employees with food handler certification Managers/supervisors Cooks Other Food Safety Practice Scoreb 4.2⫾3.9 813⫾2,205 598⫾484 2.8⫾2.0 9.0⫾2.2 10.0⫾16.9 2.5⫾1.9 4.5⫾4.7 2.8⫾1.9 67.4⫾14.1 a SD⫽standard deviation. The score was determined by dividing the number of “yes” answers on the assessment by the total number of “yes” and “no” responses, and multiplying the score by 100. b used to assess differences in attitudes and food safety knowledge among managers, cooks, and other foodservice employees. A Cronbach ␣ reliability coefficient was calculated to determine the reliability of attitudinal items (10). A KR-20 was done to determine the internal consistency of the knowledge test (11). A food safety practices score (FSPS) was determined for each school based on the objective and subjective criteria from the assessment form. Regression analysis was done to determine the relationship between manager demographics and the FSPS and the relationship between school district demographics and the FSPS. RESULTS School districts participating in the study had approximately four schools and averaged 1,813 students (Table 1). Of the 40 schools visited, 25 had regional kitchens that delivered food to an average of 2.7 satellite kitchens. All schools used conventional foodservice production systems. The majority of managers in these school districts was female, had received a high school diploma or equivalent, and had 15 or more years of school foodservice management experience (Table 2). Most of the people in charge of school foodservice had the title of foodservice director or operations manager and were between the ages of 40 and 60 years old. Twenty-nine of 40 managers had food handler certification such as the National Restaurant Association Educational Foundation’s ServSafe威(Chicago, IL). Food Safety Knowledge and Attitudes Of 401 tests distributed, 309 tests (77.7%) were returned. The food safety knowledge of employees was high. A majority of respondents (64.4%) had not taken a food handler certification course. The KR-20 was 0.62, an acceptable reliability. The mean knowledge score was 15.9⫾2.4 (20 possible points). Mean scores and standard 182 February 2004 Volume 104 Number 2 n Demographics Age (y) 20-29 30-39 40-49 50-59 ⱖ60 Sex Male Female Position District director Operations manager Supervisor Other Highest level of education completed Less than high school diploma or equivalent High school diploma or equivalent Associate degree Bachelor’s degree Other Number of years of school foodservice management experience ⬍5 5-9 years 10-14 years ⱖ15 Food safety certificationa Yes No a 1 7 14 15 3 1 39 13 10 5 10 1 27 7 3 2 9 7 7 17 29 8 Several participants declined to answer so number does not equal 40. deviations for school foodservice employees were as follows: managers (n⫽30, 17.9⫾1.1), cooks (n⫽108, 15.8⫾2.3), foodservice assistants (n⫽52, mean 15.7⫾2.5), and other employees (n⫽50, 15.7⫾2.4). Performance on the knowledge test varied significantly based on the job performed. Managers had higher knowledge test scores than other employees (F⫽10.10, Pⱕ.001). Managers were more likely than employees to have a food safety certification. There were no differences in knowledge test scores among other employees. There was no difference in knowledge test scores for employees who had completed a certification course and those who had not. Food safety knowledge questions most frequently answered incorrectly were related to sanitizer concentration and cooling and thawing practices. The most commonly missed item was the immersion time for quaternary ammonium sanitizer solutions, with 65% of respondents answering incorrectly. It should be noted that 23 of the 40 districts surveyed used quaternary ammonium as a sanitizer. Half of the participants incorrectly responded to questions about the time limit and pan depth to cool chili to less than 41°F. Questions about appropriate thawing methods, reheating temperature of complex foods, and final rinse temperature for thermal dish machines also were missed by 40% to 50% of participants. Overall employee attitudes toward food safety were Table 3. School foodservice employees’ attitudes about food safety (N⫽309) Attitude statementa I am responsible for making sure that foods served to children in my school are safe. Safe food handling is an important part of my job responsibilities. I believe that how I handle food relates to food safety. Learning more about food safety is important to me. Children can easily get foodborne illness. I would like to be certified in food safety because I think that it would help me do my job better. MeanⴞSDb 4.8⫾0.5 4.8⫾0.5 4.8⫾0.5 4.6⫾0.6 4.4⫾0.8 4.2⫾0.8 a A 5-point rating scale with 5⫽strongly agree to 1⫽strongly disagree was used for responses. b SD⫽standard deviation. favorable. Mean attitude scores for the six items ranged from 4.2 to 4.8 (Table 3). A Cronbach ␣ coefficient was calculated for the attitude items and found to be reliable (␣⫽.71) Mean attitudes about food safety were not different for managers and employees. Assessment of Food-handling Practices Overall results indicated that proper food-handling practices often were not being followed in many school foodservice operations (Table 4). Most foodservice operations were not measuring and recording food temperatures. In most operations in which food temperatures were measured, temperatures were not recorded. Stem-type thermometers were the most common type of food thermometer used in school foodservice operations. However, inaccurate temperatures may be used because many employees reported that they did not calibrate thermometers, and thermometer calibration records were not found in any of the participating schools. For food temperatures taken by the research team, temperatures of cold foods were frequently (n⫽18) more than the recommended 41°F, while a majority of operations (n⫽34) held hot foods held above 140°F. Inadequate handwashing practices were observed in most operations. Although handwashing may have been observed, frequency and poor technique (length of time, not rubbing the hands together enough to clean hands sufficiently, and not using a towel to turn off faucet) were problems noted. Dishroom staffing often was inadequate. Only one employee was working in the dish area during peak service times at several sites and those employees were observed dipping hands in sanitizer solution repeatedly between handling dirty and clean dishes. This practice is not recommended because it has not been shown to reduce the number of bacteria on the hands to safe and acceptable levels and the sanitizer solution effectiveness is reduced each time organic matter is introduced into the solution. Improper sanitizing was observed. Fill lines on multiple-compartment sinks usually were not preset to assist employees with preparing adequate sanitizer concentration. Sanitizer concentration usually was not checked and recorded and often was incorrect because employees did not have specific guidelines. In several operations, detergent was mixed with sanitizer to “save steps” in the cleaning process, which reduces sanitizer effectiveness. Other common problems noted during assessments were improper cooling and thawing. Employees in several operations were observed thawing meat and pasteurized eggs at room temperature, and some employees reported thawing meat overnight. Improper cooling practices were observed. Cooling of foods usually was not documented and employees could not report the proper procedure. Although improper cooling of foods was observed at some schools, a majority of schools were not cooling leftovers for reuse. The FSPS calculated based on these observations helped determine an overall assessment of the operation for purposes of comparison. The score was determined by dividing the number of “yes” answers on the assessment by the total number of “yes” and “no” responses, and multiplying the score by 100 (Table 1). A response of “yes” indicated that the practice was present or that practices were observed being done properly for a majority of the observation time. Areas that were not observed or not applicable were not included in the calculation. Multiple regression analysis was done to determine the relationship of school manager demographics with FSPS. Food safety practice scores were higher in schools where managers had a food safety certificate (␤⫽⫺0.383, P⫽.019). A stepwise multiple regression method was used to explore relationships between foodservice employee demographics and FSPS. School districts with foodservice employees who had passed a food safety certification course also had a higher FSPS (␤⫽0.410, P⫽.030). Scores did not differ based on age, years of experience, or education level of the school foodservice manager or school district size and number of foodservice employees. DISCUSSION The limited research related to food safety in schools indicates food-handling problems need to be addressed, and results of this study are consistent with that conclusion. Time and temperature errors and inadequate handwashing are two practices identified as concerns in schools (3,9,12-14). Research in central food production systems also indicates that time and temperature errors occur (12,14,15). Connors et al (16) found that some school foodservice managers did not know the recommended holding temperatures for milk; thus, knowledge of food safety is another problem. The trend of increasing numbers of school foodborne illness outbreaks and research documenting concerns with food-handling practices demonstrates the need to implement HACCP in school foodservice. Although the need seems evident, only a small percentage of schools have implemented a HACCP system. In Hwang et al’s study (17) 13% of school corporations in Indiana had implemented HACCP, and Giampaoli et al (18) found that less than 30% of directors reported implemention of HACCP. Research is available on implementation of HACCP prerequisite programs in schools (19-21), factors that influence HACCP (22), attitudes and challenges to implementing HACCP (18,22), and best practices and implementation strategies for successful HACCP programs (23). Results of this study can be used to develop programs for implementing HACCP procedures in Iowa school foodservice operations. Because this study was done only in Iowa, generalizing these findings may be limited, but the Journal of THE AMERICAN DIETETIC ASSOCIATION 183 Table 4. Baseline food safety assessment of school foodservice operations (n⫽40) Observed procedure Food Temperature/Time Control Adequate cooking to required internal temperatures for PHF Hot foods held above 140°F Staff demonstrates knowledge of proper cooking temperatures for foods Cold foods held at 41°F or below Temperatures are checked and recorded prior to service Calibrated thermometers are used to check temperatures Leftovers are reheated rapidly to 165°F in 2 hours Rapid cooling methods in place to achieve 140°F to 70°F in 2 hours; 70°F to 41°F in 4 additional hours Adequate cooling of cooked/prepared foods Personnel Proper personal hygiene practices observed Employees observed with hair restraints and clean uniforms Employees with infections restricted/excluded Employees observed washing hands as needed Food Handling/Source Use gloves/utensils as needed Foods are properly labeled and dated Storage Dry storage temperatures are between 50°F and 70°F Raw and cooked foods are stored separately Food stored in proper containers Food is stored at least 6” above floor throughout the facility Freezers temperatures are checked at least daily Refrigeration temperatures are checked at least daily Milk Refrigerators temperatures are checked at least daily Freezer temperatures are documented with corrective action as appropriate Refrigeration temperatures are documented with corrective action as appropriate Milk refrigeration temperatures are documented with corrective action as appropriate Ware Washing Adequate warewashing facilities Mechanical sanitizing at ppm/ °F final rinse Manual sanitizing at ppm/ °F Manual washing ppm/temperature documented Mechanical washing ppm/temperature documented Facility Proper hand washing sink is located in food prep area with proper drying and is accessible Walls, floors, ceiling, lighting adequate for food production Food contact surfaces are clean, designated, and maintained. Areas are properly ventilated; clean and maintained Premise maintained inside and outside Non-food contact surfaces clean and maintained Service Trays are dry and clean Silverware is dry and clean Sneeze guards present on serving line as appropriate a Yes No 36 34 25 21 12 11 8 4 3 2 5 15 18 28 22 3 6 6 33 29 26 26 6 11 2 13 32 27 8 13 38 32 30 25 24 23 17 6 5 5 2 7 10 15 16 17 22 34 35 34 38 35 25 1 2 5 6 35 39 38 38 34 35 35 27 2 2 6 5 5 13 38 39 27 2 NOBa NAb 2 1 1 6 26 28 30 1 3 2 1 1 12 1 1 1 1 4 2 5 3 1 13 Not observed at the time of assessment. Not applicable to the operation. b results suggest areas of focus for the development of HACCP systems and related prerequisite programs in school foodservice operations. Initial results indicate that employees in school foodservice may have sufficient knowledge about food safety but need assistance in developing prerequisite programs in preparation for HACCP. Although food safety knowledge scores were high, food-handling practices were not always consistent with accepted standards. Areas of improvement include training and education about appropriate food-handling practices and increased documentation of food safety 184 February 2004 Volume 104 Number 2 practices, including end-point temperatures, refrigerator and freezer temperatures, and dish machine effectiveness. Food safety education should be a priority for both managers and employees as indicated by the fact that operations with individuals with food safety certification used more appropriate food safety practices. Results from this study are consistent with previous research evaluating food-handling practices in schools (9,24). Additional documentation is needed to substantiate that appropriate food-handling practices are occurring in school foodservice operations. The recording of control points and critical control points was not prevalent in the study sample. Operations that are documenting practices as part of prerequisite programs are more likely to build effective HACCP systems. School foodservice managers need to facilitate employee involvement and empower them to make HACCP procedures an integral part of school foodservice operations. CONCLUSIONS ● ● ● Dietetics professionals need to assess the current status of food safety prerequisite programs in their operations and strengthen them according to accepted industry practice and standards. Managers need to become familiar with current food safety information and make necessary improvements in food-handling practices. Written standard operating procedures need to be developed and implemented in school foodservice operations. Documentation of food safety practices and critical control points may be lacking in many school foodservice operations. School foodservice managers need to develop formal practices for documenting relevant food safety information as part of routine daily operations. Developing or strengthening prerequisite programs is one of the first steps to building effective HACCP systems. This research project was funded by the USDA Cooperative States Research, Education, and Extension Service, Project No. 2001-51110-11371. The contents are solely the responsibility of the authors and do not necessarily represent the views of USDA. References 1. American Dietetic Association. Position of the American Dietetic Association: Food and water safety. J Am Diet Assoc. 1997;97:184-189. 2. Mead PS, Slutsker L, Dietz V, McCaig LF, Bresee JS, Shapiro C, Griffin PM, Tauxe RV, Food-related illness and death in the United States. Emerg Infect Dis. 1999; 5:1-35. Available: http://www.cdc.gov/ ncidod/eid/vol5no5/mead.htm. Accessed November 20, 2002 3. Gilmore SA, Brown NE, Dana JT. A food quality model for school foodservices. 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