GTCHD created a process map to outline the current process for scheduling students for a ServSafe course and exam. Using the process map, the GTCHD
QI Team identified the following problem areas:
There is no standard policy for identifying specific needs regarding language or disability. Even though students may request a non-English book and exam, the course is only offered in English.
No translator available for Chinese food service workers to ask ServSafe instructor questions from textbook.
No follow-up survey for students to measure course and exam quality.
Little follow-up for students who failed exam to determine root cause (no follow-up for Chinese students).
GTCHD employed a fishbone (cause-and-effect) diagram to determine possible causes of the low ServSafe exam passing rate among food service workers from Chinese restaurants. The most significant factor was identified as communication problems between GTCHD staff and Chinese restaurant staff due to language barriers. During this exercise, it was apparent that many assumptions were made regarding issues within the Chinese restaurants. GTCHD decided that a focus group of restaurant owners/managers would be helpful to determine the perspective from our clients viewpoint. The GTCHD QI team held a focus group meeting for owners/operators of Chinese restaurants on June 22, 2010. The meeting began with a welcome and introduction period. Once the group was comfortable, the QI team presented the current status of food safety training for Chinese restaurants, including the low ServSafe passing rate among Chinese students. One of the restaurant owners speaks English fluently and was able to act as interpreter between the QI team and the other owners/mangers. There was much discussion regarding the demographics of Chinese food service workers and ways to communicate.
The QI team presented the focus group with an exercise known as the Nominal Group Technique (NGT), which is used to prioritize and generate a course of action. The NGT exercise started with posing a question pertaining to problems that exist regarding food safety training for Chinese food service workers. Each focus group member was polled to answer the question, and then the answers were listed on a large dry-erase board. Each group member was asked to prioritize each of the answers using a ranking system. The figure below illustrates the results of the NGT exercise in order to further identify the root cause, an interrelationship diagraph was employed to study the cause-and-effect relationship between prioritized answers from the NGT exercise. The answers from the NGT exercise were arranged in a circle, and then a line was drawn between answers if a relationship exists. Next, an arrow was drawn on the line pointed to the item that is most affected by the other. The number of arrows going in and the number of arrows stemming from each cause were counted. The factor or cause with the most outgoing arrows is ranked the highest. In this case, the cause “No Training in Chinese” was ranked the highest and correlates with results of the other tools used to identify the root cause of the low ServSafe passing rate. “Small Labor Force” was also identified as a cause that has significant influence on the other factors. However, the problem of a small labor force is not a factor that can be controlled by GTCHD; therefore, the QI team focused on the issue of “No Training in Chinese.”
The aim statement was revised to account for the findings regarding the root causes. The GTCHD QI team identified potential solutions based on root cause analyses and focus group data. The QI tools and focus group clearly identified the language barrier as the root cause for the low ServSafe passing rate among Chinese food service workers. One potential solution was evident in order to meet the requirements of the AIM statement: Structure a ServSafe course specifically for Chinese food service workers. The following criteria would be key components of the improvement:
1. Teach the course in Simplified Chinese (Mandarin) using a Chinese instructor or interpreter.
2. Structure the course to meet the needs of the student’s busy schedule.
3. Provide the course, Chinese textbook, and Chinese exam free of charge to encourage all area Chinese restaurants to participate by sending as many employees as possible.
The GTCHD QI team developed an improvement theory to increase food safety knowledge among Chinese food service workers. The outcome of the improvement theory is described as follows:
If GTCHD provides a ServSafe course that is taught using the Simplified Chinese language by means of a Chinese instructor/ interpreter, Chinese text books, and Chinese exam forms, then Chinese FS workers will demonstrate a 20% increase in the ServSafe exam passing rate.
If GTCHD schedules the Chinese ServSafe course on a Monday and Tuesday, which are slow days for Chinese restaurants, then the number of potential students will be maximized.
If GTCHD offers the Chinese ServSafe course free of charge, then Chinese restaurant owners will be more likely to send kitchen staff to the training. In order to test the theory, GTCHD planned a Chinese ServSafe course and exam.
The GTCHD QI team searched for a Chinese ServSafe instructor. Availability of a certified ServSafe instructor who teaches the course in Chinese was minimal. Also, the instructor who was available charged a significant amount of money for services. As recommended by the QI team’s mentor, GTCHD contacted Jean Chang, Epidemiologist from Public Health Muskegon County, to inquire about interpretation services. Jean Chang speaks Chinese and English fluently and recently helped teach a Chinese ServSafe class for Muskegon County Chinese restaurants. Jean agreed to assist GTCHD with a Chinese ServSafe course.
GTCHD collaborated with Dorothy Wicks, Genesee County Health Department Environmental Health Supervisor, who provided GTCHD with a professionally produced DVD of a Chinese ServSafe course hosted by Genesee County Health Department and taught by Sheree Lin, PhD, a certified ServSafe instructor.
The GTCHD QI team scheduled a special 2-day Chinese ServSafe Course for Monday, August 30, and Tuesday, August 31, 2010. The 2-day course structure was based on successful Chinese ServSafe courses offered by Genesee County Health Department and Public Health Muskegon County. Also, Monday and Tuesday were selected based on the recommendation of the Chinese Restaurant Focus Group that those days were the best to conduct training due to low customer volume in the restaurants. GTCHD developed a flyer advertising the Chinese ServSafe Course and had it translated into Simplified Chinese (Mandarin). The flyer was hand-delivered to all the Chinese restaurants in Grand Traverse County 6 weeks prior to the course. Also, the flyer was sent to all neighboring health departments and a message regarding the class was sent to the Environmental Health Directors e-mail listserv. Despite the advertisement and follow-up visits and phone calls to area Chinese restaurants, only eight students signed up for the class. The ServSafe textbook was distributed to the students 3 weeks prior to the course.
The Chinese ServSafe course proceeded using a combination of the Chinese ServSafe video presentation and live discussion and review with Jean Chang. Also, the GTCHD ServSafe instructor, Tom Buss, interacted with the students using Jean Chang as the interpreter. Most of the students were engaged in the class discussions and asked questions tailored toward individual experiences and situations.
Thanks for sharing your work. Your future plans sound quite interesting, and I'm wondering if you've been able to make any progress in developing incentives that promote a vested interest? You also talked about developing another aim statement, and I'm wondering what that is/was? There were many interesting items under "other information" - has any of this information been used to develop additional interventions? I look forward to learning more about your work!
Additional work with Chinese food service workers
Thanks for your questions and comments. To date, EH staff with Health Department have not been able to continue with this project. Basically, staffing, funding, and several changes within the Department have prevented additional work. However, the food service inspectors have learned from the project and adopted methods of teaching food safety when doing inspections. This translates to more basic food safety information in simplified Chinese and more hands on training. The Department does plan on conducting a Chinese version of our "Food Safety Basics" program. Our new aim statement would center around this training which we would hire a translator to help teach the class in simplified Chinese. There would likely be a pre-test and a post-test for the class so that improvements could be measured. The class would cover the basics of food safety with heavy emphasis on hands on training and visual aids. Regarding vested interest, we have not worked on that issue. Perhaps the theme for the next focus group.
Daniel R. Thorell, M.S., R.S.
Grand Traverse County Health Department
Environmental Health Department
2650 LaFranier Rd
Traverse City, MI 49686
Thank you for submitting this
Thank you for submitting this project. We are currently writing a grant for a QI project to improve efficiencies and effectiveness (communication and customer service) with non-English speaking operators and ESL operators.Your work will help to inform our own.