Tri-County Health Department (TCHD) is a local health department that serves Adams, Arapahoe and Douglas Counties in Colorado, whose combined population totals more than 1,343,000. TCHD staff conducts over 10,000 inspections of our 4,200 licensed retail food establishments annually. Various parts of our staff’s retail food training are received from the State Health Department or we conduct them internally ourselves. Due to a staff departure in early 2000, Tri-County Health Department found itself without any in-house expertise in cross-connection and backflow prevention related to plumbing in food establishments. In response, two employees were selected to attend a week long program whose focus was the training and certification of technicians to test and repair backflow prevention devices. While the training was certainly comprehensive, it was costly, and did not address what was soon realized to be a bigger issue: TCHD’s retail food establishment inspectors were not citing cross-connection violations because their “knowledge and comfort level” with the subject was low. Since water is consumed and is also used to clean everything in a food establishment, ensuring its purity is as high a priority to prevent contamination that could lead to illness of the public. Each year, lack of, or improper applications of backflow prevention devices allow toxic substances, from sewage to industrial chemicals, to enter the potable water supply and sicken many. To develop and maintain the competency of TCHD’s food establishment inspectors on the subject, it was decided that a training program should be developed and presented once to all food establishment inspection staff, and then as often as necessary to train new staff or as a refresher for existing staff. The primary objective of the program is to provide staff with a working knowledge of applicable regulations, basic principels of cross-connection control and backflow prevention, and available control devices so they could better identify problems in food establishments and communicate the corrective actions needed.
Thus “The Backflow Roadshow” (BFRS) was developed. It is a 1 ½ to 2 hour presentation that features a 130 slide PowerPoint program, supplemental handouts, and a wide variety of plumbing fixtures and backflow prevention devices (BFPD) for “hands-on” examination by attendees. The BFRS was developed entirely in-house, with invaluable advice from representatives of the Colorado Backflow Prevention Association and the International Association of Plumbing and Mechanical Officials. Most of the slides were obtained from staff photos of actual situations in local establishments. The plumbing fixtures and BFPD’s were donated by manufactures and distributers, or rescued from condemned buildings. Displays were constructed of scrap lumber, hardware, and paint. The BFRS debuted in 2002, and has been an integral part of TCHD’s training program for new and existing food establishment inspectors ever since. Now all of TCHD’s over two dozen inspectors have the information needed to recognize and evaluate a cross-connection situation and select an appropriate BFPD to rectify the violation.
The BFRS’s continuing success can be attributed to the fact that it was designed specifically to train small groups on a specific topic, and incorporated the following characteristics:
• Touches all key areas, but is not overly long.
• Supplemental handouts effectively summarize important principals.
• Hands-on examination of hardware likely to be seen in the field.
• Slides of situations likely to be encountered.
• Presented to small groups (< 20), allowing an informal atmosphere and plenty of questions and answers
• Can be presented by a single individual, anywhere within driving distance, and on short notice.
These features have made the BFRS a frequently requested training program popular with local health departments throughout the state.
Health Issues
It had been identified that TCHD environmental health staff lacked the appropriate knowledge to identify regulatory deficiencies with back flow prevention devices within our regulated retail food establishments. And as regulators we had a difficult time providing educational feedback to our licensed food operators on the appropriate methods of protecting our water supplies through the use of back flow prevention devices.
The Colorado Retail Food Establishment Rules and Regulations identify the unprotected connection of a water supply system to any source of pollution or contamination to be a Critical Item Violation, requiring corrective action in a timely manner. While the Colorado Retail Food Establishment Rules and Regulations cite the same or similar plumbing codes adopted and employed by building officials, building officials typically scrutinize the water service lines to the building only. Plumbing connections to equipment inside the building are left to the food establishment inspectors of the local health department. To effectively enforce the requirements of the applicable codes, it is imperative that inspectors receive competent instruction in cross-connection control and backflow prevention.
This training provided the TCHD Environmental Health staff with the appropriate knowledge to effectively identify deficiencies in back flow prevention protection to water supplies and to consistently convey the appropriate educational information to our operators. This reduced operators who owned multiple food business from receiving conflicting information on what type of back flow device was need for a particular equipment application.
Innovation
The toolkit is not in NACCHO’s Toolbox. Our tool was unique in that there is no backflow prevention training in the State of Colorado that provides easily accessible and relevant training to environmental health inspectors. The availability, relevancy and low cost guided the development of this training. The Food and Drug Administration (FDA) training program, featuring both lectures and tours of local restaurants, is excellent, but is offered infrequently, and is an all day affair, making it difficult to arrange training for the entire staff. Professional or trade educational programs, such as the Colorado Backflow Prevention Association Annual Conference, are cost prohibitive, and typically focus on advanced topics unrelated to food safety, such as testing and repair of back flow prevention devices (BFPD).
The BFRS, in contrast, is tailored to bring the staff of a local health department up to speed quickly and cost effectively. The slide show presents inspectors with real life situations and ties them directly to the regulations they are tasked to enforce. The collection of BFPD’s, a.k.a., the “BFRS Petting Zoo”, allows them to handle every BFPD they are ever going to encounter in the field. The inquisitive among them may even take them apart, as long as they reassemble them, something impossible to do with a photo or slide. The illustrated handouts are designed to refresh their memories whenever a brief review is needed, and to educate food establishment operators quickly. And the BFRS is a constantly evolving presentation. For instance, although drainage of equipment is technically not a cross-connection/backflow issue, questions on the topic always come up, so now a section on drainage of equipment is a permanent feature of the BFRS.
Primary Stakeholders
Local Health Department and Regulated Establishments
Role of Stakeholders/Partners
That public exposure resulted in a stream of requests from other organizations for presentations to their staffs, and, the origin of the “Roadshow” part of the presentation’s name.
LHD Role
TCHD was the lead in bringing this toolkit to local health departments, private industry and educational institutions in Colorado. It was originally planned to present the BFRS internally at TCHD 1 to 2 times annually, depending on need, which is a function of staff turnover. However, in 2004, it was presented at the Colorado Environmental Health Association’s Annual Education Conference (AEC) in Breckenridge, Colorado.
Since that time, it has traveled to the Wyoming Environmental Health Association AEC, Rocky Mountain Food Safety Conference, the Colorado Backflow Prevention Association Annual Conference, the Colorado Department of Environmental Health and Environment’s Consumer Protection Division, City of Denver Department of Environmental Health, Pueblo County Health Department, El Paso County Health Department, Northeast Colorado Health Department, The Colorado Department of Public Health and Environment’s Advanced Food Safety Conference, and participated in a day long regional seminar in Grand Junction, Colorado.
Lessons Learned
Recently, TCHD’s internal BFRS presentations have been opened up to the regulatory compliance officials of local school districts, supermarket chains, and a local university, a practice that will hopefully expand in the future.
Implementation Strategy
Since its inception, the BFRS has been presented to new and existing TCHD staff at least once per year. More recently, a second in-house presentation has been made annually to TCHD staff plus interested individuals from outside the organization by invitation.
The BFRS has never been formally advertized; all requests for presentations outside of TCHD are generated by word-of-mouth, primarily through participation in the state-wide Food Program Managers committee quarterly meetings. Demand for the BFRS is as inevitable as it is cyclical: when staff turnover occurs at a local department it results in low ebb in cross connection control proficiency and a BFRS is requested and scheduled.
Process & Outcome
The BFRS proved to be a valuable tool for training food establishment inspectors. The first indication of its effectiveness was the great increase in the number of plumbing violations cited on inspection reports, followed closely by a flood of phone calls from restaurant operators and their plumbers seeking advice on how to correct all these “new” violations. This, in turn, has led to changes in industry practices. Early on, one of the most common cross-connection violations was an unprotected soda carbonator. Local beverage distributors responded by permanently installing an approved BFPD on every soda carbonator sent into the field, so that this violation is now relatively rare. Unfortunately, data on the incidence of violation citations and phone consultations were not collected, and are not available. However, cross-connection violations are today seldom cited, which is due to widespread compliance, not ignorance, and that ultimately is the purpose of the Backflow Roadshow.
Objective 1: To evaluate the effectiveness of the BFRS, a Before and After test was administered to the 37 attendees of 3 BFRS’s presented in February, March, and August of 2011. The average score on the Before test was 54%, and the average score on the After test was 84%, an increase of 30 percentage points demonstrating a significant gain in knowledge
The BFRS consists of three major components: a presenter knowledgeable in BFPDs, the PowerPoint slide show, and the collection of backflow prevention devices. The PowerPoint show is constantly updated with new/improved slides; the hardware collection, being mostly metal, has proved durable. Currently we have one presenter who is very knowledgeable in the area of BFPDs. To keep the program sustainable over time TCHD plans to look at cross training at least one other staff at a higher level so they too can present at future trainings and it will provide some depth should someone resign or retire.
So long as there is demand for the BFRS, and a willing and knowledgeable presenter remains available, the BFRS shall continue.