# Improving communication and collaboration between Epidemiology and Environmental Health programs on foodborne illness investigations

# 2007 - 2008 

# Environmental Public Health Leadership Institute Fellow:

# Barbara D. Will

*Quality Improvement Director;* Manatee County Health Dept.

*410 6^th^ Avenue East*

*Bradenton, FL 34208*

*barbara_will@doh.state.fl.us*

# Mentor:

### **CAPT Steve Inserra; R.S., R.E.H.S.**

*Senior Epidemiologist;* Centers for Disease Control and Prevention

# Acknowledgements:

### **Dr. Gladys Branic; M.D., M.P.H.**

*Director;* Manatee County Health Department

### **Tom Larkin**

*Environmental Health Director;* Manatee County Health Department

### **Darlyn Hughes; R.N.**

*Epidemiology Nurse;* Manatee County Health Department

### **Greg Kearney; M.P.H., Dr.P.H., R.S.**

*Environmental Epidemiologist;* Florida Department of Health

### **Mike Friedman; M.P.H.**

*Regional Environmental Epidemiologist;* Florida Department of Health

![](media/image1.jpeg){width="1.375in" height="0.6388888888888888in"}

# EXECUTIVE SUMMARY:

The goal of this project is to improve the communication and
collaboration between Epidemiology (Epi) and Environmental Health (EH)
on foodborne illness investigations at the Manatee County Health
Department. For the past few years, there has been an apparent
disconnect between the two divisions, as evidenced by cases of illness
investigated without the participation of one or the other, and the lack
of referrals for investigation based on the enteric disease rate.
Investigations of foodborne illness outbreaks performed without
competencies in both sciences can result in misleading conclusions which
in turn can adversely impact the rates of secondary cases of illness.
Or, new cases may occur because the condition that caused the primary
case of illness was not eliminated. Because many foodborne illnesses
have the potential to be fatal, the impact of an incomplete
investigation on public health could be tragic. To get to the root cause
of the current lack of communication, fact finding meetings were
initiated with all the identified stakeholders. It was discovered that
an imperfect knowledge of each other's existing policies and guidelines
was the basis of the present situation. An action plan was implemented
to undertake strategic activities to improve inter-division
communications. The first result was a protocol for assessing incoming
complaints calls or disease reports, in which the roles and functions of
each division were defined (). The second result was a process map (or
flow chart) to be aligned with a detailed operating procedure to further
increase the understanding of each division's responsibilities (). Final
review and acceptance of this communication protocol is scheduled for
March 2008. Future steps to sustain this positive momentum include
developing a training module, to ensure competencies in these
investigations. The ultimate objective is the creation of an "EpiTeam",
consisting of staff members from the Epidemiology, Environmental Health
*and* Nursing divisions within the Manatee Health Department, to assess
complaints of foodborne illness ensuring collaboration on *all*
foodborne illness investigations.

# INTRODUCTION/BACKGROUND:

In Florida, Chapter 64D-3 of the state administrative code identifies
the communicable diseases that are required to be reported to the
Department of Health. Of these reportable diseases several are
classified further as enteric diseases; they are campylobacteriosis,
cyclosporiasis, cryptosporisis, *E. coli* O157:H7, shigellosis,
salmonellosis, giardiasis, *vibrio cholerae* and hepatitis A. As
laboratories and/or medical facilities confirm a case(s) of any one of
these enteric illnesses, they are required to report it to their local
health department and at the Manatee County Health Department,
specifically to the Epidemiology Division. Additionally, state statute
provides that when food is the suspected cause of any illness, it is
considered a foodborne illness complaint and should be referred to the
Environmental Health Division for investigation. While it is not the
only manner of transmission, contaminated food is often the culprit in
the transmission of the aforementioned enteric diseases. Unfortunately,
the trend over the last four years in Manatee County indicated that none
of the confirmed cases of these diseases reported to the Manatee County
Health Department were referred to the Environmental Health Division for
investigation. This is despite the fact that the enteric disease rate
has remained constant or has increased over the course of these years.
In fact, Manatee County had the lowest numbers of foodborne illness
investigations in a four county region, despite the fact that the
enteric disease rate per 100,000 population was fairly even.

In one food related outbreak in 2006, the Epidemiology division
investigated two cases of hepatitis A, which involved a site visit to a
school and a child care, without communicating with Environmental
Health. Later an Epidemiology publication declared that the food
handling at the school and child care (both facilities were regulated by
Environmental Health) was "satisfactory"; however the persons
investigating the outbreak were not certified in the food protection
program. Nor were the proper communications made to the Regional
Environmental Epidemiologist. The food handling educational information
imparted to the school and child care was contradictory to their
licensing regulations, and could have led to more cases of hepatitis A.
Needless to say, tensions between division employees mounted when this
came to light. Investigations of this nature must come to an accurate
conclusion as to the cause of the illness, in order to contain the
outbreak and to prevent more cases. A non-collaborative climate in the
face of a large, serious outbreak of a food related disease would make
it difficult at best to perform a cohesive investigation which depends
upon open communication throughout the process.

So what is the public health significance here?? What many community
members and leaders don't realize is that these diseases can cause
severe symptoms in our vulnerable populations such as young children,
seniors, and those who are immune-compromised. In some cases, the
complications from foodborne illness can lead to death. Due to the fact
that secondary cases of foodborne illness can occur via direct
transmission from the initial case; *and* additional cases can occur if
the situation that caused the initial illness (infected food handler,
improper cooking temperatures, etc.) is not corrected, an uncontained
outbreak can pose a significant threat to public health. While the
current absence of collaboration between Environmental Health and
Epidemiology is only mildly inconvenient, when contemplating the
investigation of a large outbreak it becomes extremely concerning. Every
effort should be made to properly investigate the cause of the foodborne
illnesses to not only prevent secondary cases, but to provide education
in the community to prevent the further spread of disease through unsafe
food handling practices.

The two division managers are aware of the ramifications of allowing the
status quo to remain and have committed to addressing the concerns and
implementing ideas for change.

The divisions agreed to team together to address this opportunity for
improvement in our organization. During face-to-face meetings and
follow-up email discussion, preliminary exploration into the reasons for
these breaks in communication between Epidemiology and Environmental
Health began. These meetings revealed a lack of understanding of each
other's roles in the investigation arena. In the outbreak where
Epidemiology performed their own investigation, the reason given was
that they didn't want to bother the Environmental Health as it was only
two cases. They were unaware that Environmental Health not only required
a food certification for investigations of food facilities, but also
regulated these facilities in particular. Epidemiology was also under
the impression that single cases of illness were not tracked and
therefore those were not referred to Environmental Health for evaluation
either. Environmental Health expressed concerns over the lack of
certification and qualifications on the part of Epidemiology to perform
site investigations on commercial food facilities. They also had
concerns that there weren't written procedures for addressing a
foodborne illness investigation, that the guidelines provided by the
state for each division had contradictions, and confusing term
definitions, and that the state forms are hard to find and use. By
identifying the root causes of the primary cause of the
miscommunications, the team was able to move forward almost immediately.

A business process mapping and an analysis session followed soon after
the first meeting, and a protocol or guideline for beginning a foodborne
illness investigation was developed and is currently in use. The
protocol identified key stakeholders and partners in the investigation
process and their contact information. This gave both divisions more
direction and streamlined the intake process. Also, key to the protocol
was the beginning of an "Epi Team", which consults with each other on
foodborne illness complaints. The next steps include developing
standardized protocols which include an investigation methodology, user
friendly forms and formalized decision trees. Also, in progress are
discussions to identify a means of measuring progress and outcomes.
Fortunately, all identified stakeholders are on board with this goal and
are willing to devote time and resources to ensuring quality
investigations in the future, thereby improving the health outcomes of
our community.

####### ***Why, despite the common desired outcome in a foodborne illness outbreak investigation, don\'t Environmental Health and Epidemiology work more collaboratively?***

####### ***Behavior Over Time Graph:***

This graph represents the key variables over time. Even though the
number of lab confirmed enteric diseases is constant or increases, the
numbers of cases referred to Environmental Health for investigation as a
possible foodborne illness has remained at zero.

####### ***Causal Loop Diagrams and applicable archetypes:***

![](media/image2.png){width="7.725in" height="5.602777777777778in"}

####### 

####### ***10 Essential Environmental Health Services:***

This project seeks to fulfill the following aspects of the 10 Essential
Services of Environmental Health (*10*):

[CORE FUNCTION: ASSESMENT:]{.underline}

> [Diagnose & Investigate]{.underline} -- Environmental health
> specialists should be able to evaluate complaints and perform field
> investigations if necessary when foodborne illness is suspected during
> an outbreak of disease. Standardized processes would ensure all
> environmental staff access to appropriate tools and contacts to make
> appropriate liaisons with other agencies, the epidemiology staff, and
> the laboratory to coordinate applicable sample collections and
> submissions for testing. Key to a competent foodborne illness
> investigation is the leadership and communication skills of the
> environmental specialist throughout the inquiry, as the environmental
> assessment will be the linchpin to the diagnosis of the source of the
> enteric disease, which in turn will provide the measures to prevent
> the spread of the illness and/or to correct the situation that caused
> the contamination.

[CORE FUNCTION: POLICY DEVELOPMENT:]{.underline}

> [Inform, Educate, Empower]{.underline} -- Information gathered from
> all team members during a foodborne illness investigation should be
> used to identify the probable source of contamination that caused the
> outbreak of disease. Measures should be taken immediately to remove
> the threat, whether it be an infected food worker, or a faulty food
> preparation process, or contaminated food. Education of the food
> service workers and managers would begin immediately upon the start of
> the investigation and continue throughout the process, including a
> written report of findings with corrective action plans for the
> prevention of future outbreaks. The community should be informed of
> the mode of transmission of the disease in order to provide them with
> the knowledge they need to act appropriately and empower them with the
> ability to protect their own health.
>
> [Develop Policies]{.underline} [& Mobilize Community
> Partnerships]{.underline} -- The ultimate goal of providing a
> standardized protocol for local public health departments to complete
> competent foodborne illness investigations, would be for the state
> environmental epidemiology division to utilize this tool to refine and
> standardize policies, procedures, processes and forms for use in all
> the county health departments. The status quo is inconsistent
> reporting and a non-standardized methodology for investigating and
> tracking these complaints and outbreaks. With this project, we hope to
> provide the means for all stakeholders in the food hygiene industry to
> communicate meaningfully on complaints of illness, and through the
> resulting investigations. This goal would require the local
> environmental health departments to develop and maintaining close
> partnerships with each other, the state environmental health and
> epidemiology divisions, several other state agencies, divisions within
> each agency, local medical practitioners and emergency facilities, as
> well as the food service industry.

[CORE FUNCTION: ASSURANCE:]{.underline}

> [Assure Competent Workforce]{.underline} -- This project is seeking to
> assure a competent workforce by defining and clarifying the role(s) of
> environmental health specialists during foodborne illness
> investigations and providing training focused on these roles.
> Increasing our capacity in this area is paramount to the health of
> Florida's citizens, as we have a not only large numbers vulnerable
> populations (the elderly and very young), but a tourism driven economy
> which is largely dependent on visitors from other areas of the country
> and the world. Our visitors and citizens should be assured that the
> food that they eat is safe. A competent investigation of complaints of
> food related illnesses is essential to the prevention of new cases
> and/or secondary cases of illnesses, thereby keeping the public
> healthy.

![](media/image3.png){width="3.75in" height="3.8125in"}

####### 

####### ***National Goals Supported*** 

1\. Describe how your project seeks to support one or more of the CDC
Health Protection Goals <http://www.cdc.gov/about/goals/default.htm>

**This project supports the CDC Health Protection Goal of Healthy People
in Healthy Places***. Through this goal the "CDC is working hard to
ensure the places we live, work, and play have safe, healthy
environments." Proscribing a competent methodology and training program
for investigating the outbreak of foodborne illness goes to ensuring
that the citizens and visitors in our state can be assured their food
sources are safe, whether they eat at home or at a commercial facility,
whether they are recreating at one of our many theme parks or on a
beach. Through competent investigations of complaints of foodborne
illness, data is gathered as to the causes of food contamination, which
in turn leads to health department guidance and education for the both
the public and the food industry on the proper methods of food handling,
thereby keeping the public safe and healthy. Education is the key to
reducing exposure to infections associated with travel, transportation
and recreation!*

2\. This project supports the following national goals as proscribed by
the CDC National Strategy to Revitalize Environmental Public Health
Services: <http://www.cdc.gov/nceh/ehs/Docs/nationalstrategy2003.pdf>

**Goal I. Build Capacity**

**Strengthen and support environmental public health services at the
state, tribal, territorial, and local levels.**

*By putting forth the effort to increase collaboration between
Epidemiology and Environmental Health we are building our capacity to
properly investigate and contain foodborne illness outbreaks,
strengthening our veracity with our customers and our stakeholders. As
our project develops, we will be providing the guidance, training , and
consultation to our field specialists to conduct a through investigation
of foodborne illness complaints; and have plans to share our findings
with the state environmental epidemiology office in an effort to keep
the momentum going and eventually reach all county health departments in
the state.*

**Goal VI. Create Strategic Partnerships**

**Foster interactions among agencies, organizations, and interests that
influence environmental public health services.**

*. "Working together to develop mechanisms for regular communication and
coordination among stakeholders" is one of the objectives of this CDC
Environmental Health goal, as well as the underlying premises of this
project. This key to the success of the continued collaboration between
Epidemiology and Environmental Health on foodborne Illness
investigations is the open communication between all stakeholders, as
these investigations involve not only the interaction between these two
divisions on a local level, but involves all the stakeholders (several
other state agencies, and local, regional and state health department
divisions) involved in the process. By working together as local public
health system to improve the process and to provide the avenues for
supplemental training and development in the areas of foodborne illness
investigations, we will be able to improve our response to this
important environmental public health function.*

+----------+------------------+-----------+-------------+-------------+
| **RES    | **ACTIVITIES**   | **OUTPUTS | *           | **IMPACT**  |
| OURCES** |                  | SHORT**   | *OUTCOMES** |             |
+----------+------------------+-----------+-------------+-------------+
| *In      | *In order to     | *We       | *We expect  | *We expect  |
| order to | address our      | expect    | that if     | that if     |
| ac       | problem or issue | that once | ac          | a           |
| complish | we will          | acco      | complished, | ccomplished |
| our      | accomplish the   | mplished, | these       | the         |
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| tivities | activities:*     | a         | will lead   | will lead   |
| we will  |                  | ctivities | to the      | to the      |
| need the |                  | will      | following   | following   |
| fol      |                  | produce   | changes in  | changes in  |
| lowing:* |                  | the       | 1-3, then   | 7 - 10      |
|          |                  | following | 4-6 years:* | years:*     |
|          |                  | evidence  |             |             |
|          |                  | or        |             |             |
|          |                  | service   |             |             |
|          |                  | d         |             |             |
|          |                  | elivery:* |             |             |
+----------+------------------+-----------+-------------+-------------+
| **[Staff | **Quality        | **I       | **Next 1 -3 | **O**nce a  |
| and      | improvement      | **nfusion | years:**    | dynamic,    |
| Time     | processes        | of        |             | proficient  |
| :]{.unde | implemented**    | Quality   | **L**ess    | process is  |
| rline}** |                  | Im        | misco       | in place in |
|          | **Activities:**  | provement | mmunication | the Manatee |
| Manatee  |                  | and       | over the    | CHD, we can |
| CHD      | **A**nalyze and  | Quality   | in          | submit the  |
|          | review current   | M         | vestigation | program     |
| Epid     | processes mapped | anagement | of          | model as    |
| emiology | at workshop      | into both | foodborne   | "best       |
|          |                  | division  | illness     | practice";  |
| Env.     | **R**equest any  | cultures. | outbreaks.  | possibly    |
| Health   | technical        |           |             | assisting   |
| Staff    | assistance       |           | **          | imp         |
|          | needed from      |           | I**ncreased | lementation |
| Quality  | stakeholders or  |           | numbers of  | in other    |
| Manager  | expert advisors  |           | enterics    | county      |
|          | to explore other |           | i           | health      |
| Partners | county model     |           | nvestigated | d           |
|          | procedures       |           | as possible | epartments. |
| DBPR     |                  |           | food borne  |             |
|          | **D**etermine    |           | illnesses.  |             |
| DOACS    | indicators of    |           |             |             |
|          | progress         |           | **          |             |
| Regional |                  |           | I**ncreased |             |
| Env. Epi | **C**reate       |           | numbers of  |             |
|          | time-line to     |           | foodborne   |             |
|          | update processes |           | illnesses   |             |
|          | (action plan)    |           | confirmed.  |             |
|          |                  |           |             |             |
|          | **C**reate       |           | **M**ore    |             |
|          | written          |           | lab         |             |
|          | procedures and   |           | c           |             |
|          | good visual      |           | onfirmation |             |
|          | guides for       |           | of illness. |             |
|          | foodborne        |           |             |             |
|          | illness          |           | *           |             |
|          | investigations   |           | *D**ecrease |             |
|          |                  |           | in numbers  |             |
|          | **C**reate means |           | of          |             |
|          | of               |           | secondary   |             |
|          | electronically   |           | cases of    |             |
|          | tracking how     |           | illness.    |             |
|          | many foodborne   |           |             |             |
|          | illness          |           |             |             |
|          | complaints are   |           |             |             |
|          | received from    |           |             |             |
|          | Epi & referred   |           |             |             |
|          | to EH & vice     |           |             |             |
|          | versa to measure |           |             |             |
|          | numbers of       |           |             |             |
|          | collaborative    |           |             |             |
|          | investigations   |           |             |             |
+----------+------------------+-----------+-------------+-------------+
| Inf      | **Foodborne      | **        | **N ext 4   | **T**he     |
| ormation | illness          | R**outine | -- 6        | over        |
| Te       | investigation    | meetings  | years:**    | arching     |
| chnology | guideline        | between   |             | vision      |
|          | implemented**    | Epi and   | **E         | would be    |
| Per      |                  | EH to     | **fficient, | for the     |
| formance | **Activities:**  | discuss   | organized   | whole state |
| Imp      |                  | latest    | inv         | to have one |
| rovement | **F**inalize and | enteric   | estigations | s           |
| Office   | present new      | diseases  | with        | tandardized |
| Peer     | pr               | reported  | clearly     | model for   |
| Advisors | otocol/guideline | to Epi    | reported    | all of the  |
| /Experts |                  | and       | and lab     | sixty-seven |
|          | **P**rovide      | latest    | supported   | (67)        |
|          | cross-training   | c         | outcomes,   | counties in |
|          | to all division  | omplaints | can sway    | Florida to  |
|          | staff on new     | of "food  | the medical | better      |
|          | procedures       | p         | profession  | prevent     |
|          |                  | oisoning" | to see the  | disease and |
|          | **B**egin        | to EH.    | benefits of | promote     |
|          | running reports  |           | reporting   | health      |
|          | on new tracking  | **I**mple | enteric     | behaviors   |
|          | system to        | mentation | illnesses   | with        |
|          | identify         | of flow   | in a timely | regards to  |
|          | benchmarks       | charts    | manner.     | foodborne   |
|          |                  | and       |             | illness.    |
|          | **S**urvey       | inve      | **B**uild   |             |
|          | stakeholders for | stigation | on current  |             |
|          | input on the     | protocols | models and  |             |
|          | workability of   | to        | develop     |             |
|          | the new          | c         | s           |             |
|          | procedures       | oordinate | tandardized |             |
|          |                  | inves     | in          |             |
|          | **U**pdate       | tigations | vestigation |             |
|          | tracking         | between   | protocols.  |             |
|          | database as      | the       |             |             |
|          | needed           | d         |             |             |
|          |                  | ivisions. |             |             |
|          | Schedule routine |           |             |             |
|          | meetings between | **I*      |             |             |
|          | EH and Epi       | *ncreased |             |             |
|          | divisions to     | numbers   |             |             |
|          | coordinate       | of        |             |             |
|          | investigations   | foodborne |             |             |
|          |                  | illness   |             |             |
|          |                  | invest    |             |             |
|          |                  | igations. |             |             |
|          |                  |           |             |             |
|          |                  | **I*      |             |             |
|          |                  | *ncreased |             |             |
|          |                  | number of |             |             |
|          |                  | lab       |             |             |
|          |                  | confirmed |             |             |
|          |                  | i         |             |             |
|          |                  | llnesses. |             |             |
|          |                  |           |             |             |
|          |                  | Increased |             |             |
|          |                  | trust and |             |             |
|          |                  | assurance |             |             |
|          |                  | of a      |             |             |
|          |                  | competent |             |             |
|          |                  | workforce |             |             |
|          |                  | between   |             |             |
|          |                  | divisions |             |             |
+----------+------------------+-----------+-------------+-------------+
|          | **Evaluation of  | **C**     |             |             |
|          | new foodborne    | ontinuous |             |             |
|          | illness          | m         |             |             |
|          | investigation    | onitoring |             |             |
|          | guidelines**     | to        |             |             |
|          |                  | determine |             |             |
|          | **Activities:**  | if        |             |             |
|          |                  | progress  |             |             |
|          | **E**valuate     | has been  |             |             |
|          | enteric diseases | made.     |             |             |
|          | reported since   |           |             |             |
|          | implementation   | **D*      |             |             |
|          | of protocol to   | *etermine |             |             |
|          | ascertain        | whether   |             |             |
|          | whether          | this is a |             |             |
|          | referrals were   | best      |             |             |
|          | made when        | practice  |             |             |
|          | indicated        | and       |             |             |
|          |                  | should be |             |             |
|          | **E**valuate     | stan      |             |             |
|          | investigations   | dardized. |             |             |
|          | conducted on     |           |             |             |
|          | foodborne        |           |             |             |
|          | illness          |           |             |             |
|          | complaints to    |           |             |             |
|          | ascertain        |           |             |             |
|          | whether          |           |             |             |
|          | technical        |           |             |             |
|          | assistance from  |           |             |             |
|          | Epi was          |           |             |             |
|          | requested when   |           |             |             |
|          | appropriate      |           |             |             |
|          |                  |           |             |             |
|          | **S**urvey       |           |             |             |
|          | stakeholders for |           |             |             |
|          | input on the     |           |             |             |
|          | collaborative    |           |             |             |
|          | efforts of the   |           |             |             |
|          | two divisions    |           |             |             |
|          |                  |           |             |             |
|          | **R**un reports  |           |             |             |
|          | on health date   |           |             |             |
|          | and performance  |           |             |             |
|          | indicators       |           |             |             |
|          |                  |           |             |             |
|          | **S**ubmit new   |           |             |             |
|          | procedure guides |           |             |             |
|          | to Health        |           |             |             |
|          | Program Office   |           |             |             |
|          | and to other     |           |             |             |
|          | CHDs for use     |           |             |             |
|          | outside of       |           |             |             |
|          | Manatee          |           |             |             |
+----------+------------------+-----------+-------------+-------------+

# PROJECT OBJECTIVES/DESCRIPTION/DELIVERABLES:

***Program Goal:***

*Improve communication and collaboration between Epidemiology and
Environmental Health on foodborne illness investigations.*

***Health Problem:***

*Investigations performed without competencies in both sciences may
result in misleading conclusions which can impact the rates of secondary
cases of illness or may not prevent the situation that caused the
illness from recurring.*

***Outcome Objective:***

*By June 30^th^, 2008, Environmental Health & Epidemiology will
collaborate on performing quality foodborne illness investigations 100%
of the time.*

***Determinant:***

*The numbers of foodborne illnesses Investigations performed based on
confirmed case referrals from the Epidemiology Division.*

***Impact Objective:***

*By December 31, 2007, develop an inter-division investigation protocol
to respond to enteric diseases that may be foodborne related.*

***Contributing Factors:***

1.  *Lack of understanding of each others roles during foodborne
    investigations.*

2.  *Lack of time to map business processes and develop new protocols.*

3.  *Lack of standardized protocols and/or enforcement from the state
    health program office.*

4.  *Number of stakeholders in the process too varied and wide-spread
    with differing protocols to be relevant to the local process.*

***Process Objectives:***

1.  *By October 31, 2007, at least three (3) strategic planning
    workshops with representatives from both of the Epidemiology and
    Environmental Health divisions to be held.*

> ***Event:** Quality improvement implemented*

***Activities:***

-   *Analyze and review current processes mapped at workshop*

-   *Request any technical assistance needed from stakeholders or expert
    advisors to explore other county model procedures*

-   *Determine indicators of progress*

-   *Create time-line to update processes (action plan)*

-   *Create written procedures and good visual guides for foodborne
    illness investigations*

-   *Create means of electronically tracking how many foodborne illness
    complaints are received from Epi & referred to EH & vice versa to
    measure numbers of collaborative investigations*

2.  *By December 31, 2007, finalized investigation guides implemented
    within the Manatee County Health Dept.*

***Event:** Foodborne illness investigation guideline implemented*

***Activities:***

-   *Finalize and present new procedure guide to all stakeholders*

-   *Provide cross-training to all division staff on new procedures*

-   *Begin running reports on new tracking system to identify
    benchmarks*

-   *Survey stakeholders for input on the workability of the new
    procedures*

-   *Update tracking database as needed*

-   *Schedule routine meetings between EH and Epi divisions to
    coordinate investigations*

3.  *By June 30, 2008, evaluate health data and performance indicators
    to assess effectiveness of new protocols.*

***Event:** Evaluation of new foodborne illness investigation
guidelines*

***Activities:***

-   *Evaluate enteric diseases reported since implementation of protocol
    to ascertain whether referrals were made when indicated*

-   *Evaluate investigations conducted on foodborne illness complaints
    to ascertain whether technical assistance from Epi was requested
    when appropriate*

-   *Survey stakeholders for input on the collaborative efforts of the
    two divisions*

-   *Run reports on health date and performance indicators*

-   *Submit new procedure guides to Health Program Office and to other
    CHDs for use outside of Manatee*

# METHODOLOGY:

*Events and Activities*

*Quality improvement activities implemented:*

-   *Analyze and review current processes mapped at workshops(container
    building exercise)*

-   *Request any technical assistance needed from stakeholders or expert
    advisors to explore other county model procedures*

-   *Determine indicators of progress (logic model)*

-   *Create time-line to update processes and assign responsibility
    (action plan)*

-   *Create written procedures and good visual guides and forms for
    foodborne illness investigations*

# RESULTS:

1.  Improved communication between the Epidemiology and Environmental
    Health Divisions

2.  Active participation by team members from both divisions relayed
    into increased understanding of each other's roles and functions

3.  Relationship building made for improved attitudes about new ideas
    and change

-   Epidemiology Division reporting all foodborne illness complaints to
    EHS

-   Epidemiology Division utilizing DOH Foodborne Complaint Form to
    refer complaints to save EHS time

4.  Implemented new investigation flow chart and call down protocol

5.  All complaints of foodborne illness are now tracked and monitored by
    Environmental Health and reported to the Regional Epidemiologist

6.  More confidence in each other's knowledge.

# CONCLUSIONS:

While the analysis between numbers of enteric diseases reported to the
health department versus the numbers of foodborne illness investigations
initiated proved to be an imperfect methodology of measuring the
communication in this area, the resulting meetings and discussions
between the two divisions opened many new avenues of collaboration.
Since, the inception of this project, a new "call-down" protocol has
been adopted and implemented by both divisions for complaints of
foodborne illness from the public. Additionally, an investigation
"manual" is in development phase. I feel positive progress is being made
on these investigations in this county, and I hope to bring it to the
state level as a "best practice" submittal once we have a chance to
evaluate its effectiveness to all of our stakeholders.

**ATTACHMENT 1:**

**Definition:**

  -----------------------------------------------------------------------
  **Foodborne Illness Outbreak**

  **An outbreak is an incident in which two or more persons have the same
  disease, have similar symptoms, or excrete the same pathogens; and
  there is a time, place, and/or person association between these
  persons.  A foodborne illness outbreak is one in which a common food
  has been ingested by such persons.**

  **Nevertheless, [a single case]{.mark} of suspected botulism, mushroom
  poisoning, ciguatera or paralytic shellfish poisoning, other rare
  disease, or a case [of a disease that can be definitely related to
  ingestion of a food, can be considered as an incident of foodborne
  illness and warrants further investigation.]{.mark}**
  -----------------------------------------------------------------------

**Food Inspection Agency Responsibilities with Phone Numbers:**

+------------------------+---------------------------------------------+
| **In Florida, three    |                                             |
| agencies have          |                                             |
| responsibilities for   |                                             |
| inspecting food and    |                                             |
| food establishments.   |                                             |
| Inspections are the    |                                             |
| first line of defense  |                                             |
| in preventing          |                                             |
| foodborne illness      |                                             |
| outbreaks.**           |                                             |
+------------------------+---------------------------------------------+
| **The Department of    | -   **Restaurants** **(both sit down and    |
| Business and           |     take-out)**                             |
| Professional           |                                             |
| Regulation**           | -   **Sandwich shops**                      |
|                        |                                             |
|                        | -   **Caterers**                            |
|                        |                                             |
|                        | -   **Most mobile food carts**              |
|                        |                                             |
|                        | -   **Most temporary events**               |
+------------------------+---------------------------------------------+
| **Division of Hotels   |                                             |
| and Restaurants**      |                                             |
|                        |                                             |
| **(850) 487-1395**    |                                             |
+------------------------+---------------------------------------------+
|                        |                                             |
+------------------------+---------------------------------------------+
| **The Department of    | -   **Grocery Stores**                      |
| Agriculture and        |                                             |
| Consumer Services**    | -   **Bakeries**                            |
|                        |                                             |
|                        | -   **Food Processors**                     |
|                        |                                             |
|                        | -   **Fast food establishments associated   |
|                        |     with gas stations**                     |
|                        |                                             |
|                        | -   **Convenience stores**                  |
|                        |                                             |
|                        | -   **Produce stands**                      |
|                        |                                             |
|                        | -   **Fish Markets**                        |
+------------------------+---------------------------------------------+
| **Food Safety          |                                             |
| Division**             |                                             |
|                        |                                             |
| **(800) 435-7352**    |                                             |
+------------------------+---------------------------------------------+
|                        |                                             |
+------------------------+---------------------------------------------+
| **The Department of    | -   **Institutions e.g. hospitals, day      |
| Health**               |     cares, prisons, and all community       |
|                        |     residential facilities, i.e. ALFs  **   |
|                        |                                             |
|                        | -   **Public and private schools**          |
|                        |                                             |
|                        | -   **Bars and lounges**                    |
|                        |                                             |
|                        | -   **Fraternal and Civic Organizations**   |
|                        |                                             |
|                        | -   **Adult Day Cares**                     |
|                        |                                             |
|                        | -   **Migrant Camps**                       |
+------------------------+---------------------------------------------+
| **Manatee CHD - EHS**  |                                             |
|                        |                                             |
| **Extension 1340**     |                                             |
+------------------------+---------------------------------------------+

# ATTACHMENT 2:

![](media/image4.wmf)

# LEADERSHIP DEVELOPMENT OPPORTUNITIES:

*I wish to express my gratitude to the institute for accepting my
application and allowing me to participate in this "once-in-a-career"
opportunity! It was truly a learning experience on every level --
personal, professional and ............mystical! Personal learning came
from discussing and comparing environmental issues, as well as family
concerns, with my classmates (some people call that "networking", I call
it making friends); professional learning came from the mentors and the
many educators from the public and private sectors that were selected to
present to our class; and mystical, because anything heard after 5 PM in
a hotel banquet room doesn't really sink in right away but mysteriously
comes back to you later in your dreams -- and right when you need it,
too!*

*I found that the majority of the seminars on leadership, teamwork, and
communication were thought provoking and directly applicable to the many
management situations that arise in the workplace. For the most part,
this portion of the curriculum served to reinforce professional
development sessions provided at the Florida Department of Health, which
is vital for "studying and practicing" and served to assure consistency
in our learning.  Particularly useful to me were the seminars on
"Leadership and Organizational Thinking" from Sherry Immediato and
"Leadership, Collaboration and Teamwork" from Cynthia Lamberth. The
weeklong Disaster Preparedness and Response training in June was
relevant to everyone in the class as no state is without its
environmental emergencies! The hands-on accounts of issues experienced
first hand by CDC and EPA response teams after Katrina were eye-opening
and informative.  I would also recommend that every class be exposed to
the "Verbal Judo" agenda. While also being wildly entertaining, it
provided relevant communication and persuasion skills that I was able to
utilize immediately. *

*I appreciated the personal development portion of the program the
most.  The 360° Skillscope Assessment, MTBI and Change Style Indicator
exercises were all new experiences for me and each series provided
meaningful, direct interpretive reports on my management and leadership
style. I believe I will be able to use those tools to guide my
individual development plans for the rest of my career!*

*I would be remiss if I didn't mention the people. The institute leaders
and staff, the mentors, and the coaches, all worked so well together to
make this year flow smoothly and seem to fly by -- the logistics of this
task must seem insurmountable each year, but they make it look
effortless. I have great respect for their mission to develop leaders in
the field of environmental health. By assuring the public of competent
leaders in this field throughout our nation, we will surely be effective
in our efforts to prevent disease and keep our environments healthy.*

*And, finally, it was awesome to have forty (40) diverse individuals
from environmental health and epidemiology programs around the country
gather together to develop their leadership skills and share information
about their respective states. I was once again amazed that no matter
how different we think we are (and we are), we are all so very much
alike in our programs and goals, and doing our best for our respective
local public health systems! Great job Class III!! And, keep plugging
away - I'll never forget you guys!*

####### ***Sincerely, Barbara D. Will***

# ABOUT THE EPHLI FELLOW(s)

Barbara D. Will began her career in public health as an Environmental
Health Specialist with the Pinellas County Health Department
Environmental Health Services Division (EHS) in 1989. She has her
Bachelor of Arts Degree in Social and Behavioral Sciences, received from
the University of South Florida (USF) in 1985. Prior to coming to work
for the health department, she worked her way up the ranks from a
Customer Service Representative to the New Accounts Manager, at a local
bank. After working at the bank for four years, Ms. Will was hired by
the Pinellas County Environmental Health Director, who at that time felt
that her communication abilities and customer service skills would be a
vital asset in the area of public health education and promotion. She is
still grateful to that "out-of-the-box" thinker!!

While Ms. Will was trained in all EHS programs (mobile home parks, group
care, sanitary nuisances, mosquito and rodent control, etc.), the
primary environmental health program at that time was food hygiene and
the majority of the work performed were food service inspections. While
at the Pinellas County Health Department, she developed and presented
many food sanitation and safety educational courses for both the
industry and the public; and became the EHS team leader, assisting the
supervisors with the training of newly recruited specialists. In 1991,
she accepted a promotion to the Department of Business and Professional
Regulation Division of Hotels and Restaurants, as the plan reviewer for
all new and remodeled restaurants in a seven (7) county district. There
she honed her food service plan review skills and participated in
developing the agency's state-wide plan review policies and protocols,
which are still in use today. She transferred back to the Pinellas
County Health Department in 1996, where she accepted a position as a
supervisor with the EHS division There she was provided with the formal
leadership and supervisory training needed to manage several
departments. She was also able to perfect database management and
software proficiency skills; and she served as the Food Hygiene
Coordinator and HACCP Instructor for the division. Her responsibilities
included coordinating the Foodborne Illness Surveillance and
Investigation program.

In 2001, Ms. Will accepted a position in database management for the
Hillsborough County Health Department EHS, and then in 2003, she began
working for the Manatee County Health Department as the Environmental
Supervisor. There she supervised all the EHS programs except drinking
water and onsite sewage. In May of 2007, she was offered (and accepted)
a management position as the Quality Improvement Director at the Manatee
County Health Department, and began her journey into public health
administration. Ms. Will has been accepted into the USF College of
Public Health Graduate Certificate program and hopes to achieve her goal
of a Master's Degree in Public Health by 2011.

# REFERENCES

1.  , Florida Administrative Code, **Disease Control**

2.  , Florida Statute, PUBLIC HEALTH, **Environmental Health**

3.  Florida Department of Health, Bureau of Environmental Epidemiology,

4.  Florida Department of Health, Division of Environmental Health,
    Environmental Health Program 150-4, : Food and Waterborne Disease
    Surveillance and Investigation

5.  *Epi Moves*, Monthly Epidemiology Newsletter Volume 4, Issue 9,
    September 2006