- Email: [email protected]
Emergency Preparedness Needs Assessment of Centralized School Foodservice and Warehousing Operations
RESEARCH Perspectives in Practice
Emergency Preparedness Needs Assessment of Centralized School Foodservice and Warehousing Operations CYNDIE STORY, MEd, RD; JEANNIE SNEED, PhD, RD; CHARLOTTE B. OAKLEY, PhD, RD, FADA; THERESA STRETCH, MS, RD
ABSTRACT Managers of onsite retail foodservice operations, particularly those in centralized school foodservice operations, are called on to provide meals during emergencies, yet there is a paucity of research on their readiness to handle emergencies. Qualitative research and a cross-sectional survey design were used to conduct a needs assessment for emergency preparedness (emergency readiness, food recalls, and food defense) in centralized school foodservice operations, including warehousing. An open-ended written questionnaire was mailed to eight foodservice directors, and responses were used to develop a written questionnaire that was mailed to school foodservice directors in 200 districts identified as having centralized food production and warehousing. Directors from 78 districts responded (39% response rate). Most districts (n⫽72) had an emergency response team, and foodservice was included as part of 63 of those teams. Not all districts had written procedures for food recalls (47 of 73), natural disasters (37 of 74), or food defense (30 of 74). Barriers to implementing emergency preparedness policies and procedures included limited money, emergency equipment, and time. Most current training related to food safety with little training related to emergency preparedness. Training on the emergency preparedness plan was done in 61 of 78 districts. Training on emergency procedures was done by less than half of the districts during the previous year. This study identified best practices related to emergency preparedness that can be implemented in onsite retail foodservice operations. Results indicate a need to emphasize emergency preparedness, develop
C. Story is a consultant, Culinary Solution Centers, LLC, Jacksonville, FL. J. Sneed is a consultant, Sneed Consulting, Stillwater, OK; at the time of the study, she was a professor, Iowa State University, Ames. C. B. Oakley is executive director and T. Stretch is a food and nutrition specialist, National Food Service Management Institute, University, MS. Address correspondence to: Jeannie Sneed, PhD, RD, Sneed Consulting, PO Box 1026, Stillwater, OK 74076. E-mail: [email protected] Copyright © 2007 by the American Dietetic Association. 0002-8223/07/10712-0006$32.00/0 doi: 10.1016/j.jada.2007.09.007
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written standard operating procedures, and train employees to be prepared to respond to emergencies. J Am Diet Assoc. 2007;107:2100-2104.
I
n 2006, the United States Surgeon General stated that “our nation is constantly under threats to our public health” from natural and man-made disasters and emphasized the need for food and nutrition professionals to be part of the first line of defense to improve emergency readiness in local communities (1). Numerous government documents guide foodservice operators on emergency preparedness, specifically emergency readiness (2-4), chain of custody and food recalls (5-7), and food defense (8-11). Research has addressed preparation of first responders’ use of respiratory protection (12), management of medical needs after Hurricane Katrina (13), and use of emergency preparedness drills in hospitals (14) and long-term care facilities (15), yet there is a paucity of research related to onsite retail foodservice operations. Centralized school foodservice operations may be a significant resource for food during an emergency situation because they are able to prepare and transport large amounts of food throughout a community. Due to the large number of students served by centralized foodservice operations, they may be of greater concern and at higher risk for breaches to food security than individual schools. Thus, the purpose of this study was to conduct an emergency preparedness needs assessment for centralized school foodservice operations, including warehousing and distribution. Specific objectives were: (a) to identify emergency preparedness policies and standard operating procedures currently used in centralized school foodservice operations; (b) to identify barriers to implementing emergency preparedness policies and standard operating procedures; and (c) to determine frequency and type of emergency preparedness training and training needs of staff in centralized foodservice operations, including staff responsible for distribution/shipping. METHODS Study Design and Sample Qualitative research and a cross-sectional survey design were used. The study sample included school foodservice directors in the 200 largest school districts in the United States identified as having centralized foodservice operations or a warehouse distribution center. The National Food Service Management Institute has developed a database of these school districts and provided mailing labels.
© 2007 by the American Dietetic Association
Questionnaire Questionnaire Development. A written questionnaire was used to gather opinions from eight experienced district school foodservice directors. Seven open-ended questions addressed current practices that support emergency preparedness, practices that need to be established to ensure that a centralized school foodservice operation is adequately prepared to respond to an emergency, facilities and equipment needed to respond to an emergency, policies and standard operating procedures related to emergency preparedness that are in place in their operations, barriers to emergency preparedness, emergency preparedness trainings attended, and type of staff training needed. This round of questioning was the basis for questionnaire development and provided content validity. Research Questionnaire. A five-part questionnaire was developed. Part 1 included five questions to determine characteristics of the school district and foodservice operation, including district participation in the federal child nutrition program, types of foodservice operations used in the district (ie, onsite kitchens, centralized kitchen serving both offsite and onsite, and centralized kitchen with no onsite service), how food is transported (hot/cold; preplated/bulk), district enrollment, and use of a centralized warehousing operation. Part 2 of the questionnaire examined practices and standard operating procedures in school districts. Items were related to district procedures, facilities and equipment, implementation, and staffing. For each item, respondents were asked to indicate if their organizations had this practice or policy in place and to rate its importance using a 5-point scale: not important, somewhat important, important, very important, or critical. Part 3 included seven potential barriers to implementing emergency preparedness policies and procedures. Respondents were asked to rate each barrier using a 4-point scale: not a barrier; some barrier but not a big impact; barrier that needs to be addressed; or critical barrier. Part 4 included 16 items related to facility and equipment requirements. Respondents were asked to indicate (yes/no) if their organization had each of the items in place and rate the item’s importance using the same scale as in Part 2. Part 5 included 18 potential areas for training. Respondents were asked to indicate (yes/no) whether training on the topic had been provided within the past year and to rate the importance of training using the importance scale used in Part 2. After each part, space was provided for respondents to write in other emergency preparedness concerns. The questionnaire was reviewed for clarity and content validity by three researchers and three school foodservice directors. The Iowa State University Institutional Review Board’s Human Subjects Review Committee approved the questionnaire and study protocol before data collection. Data Collection. A cover letter, questionnaire, and postagepaid return envelope were mailed to each school foodservice director in the sample. Four weeks after the initial mailing, researchers mailed a follow-up letter, survey, and postage-paid return envelope to encourage response. Data Analysis. Survey data were compiled using SPSS-X (version 13, 2005, SPSS Inc, Chicago, IL). Descriptive
statistics (ie, frequencies, means, and standard deviations) were calculated and crosstabs with 2 examined relationships between current implementation of practices and importance ratings. RESULTS AND DISCUSSION Foodservice directors from 78 school districts responded (39% response rate). Most districts had onsite kitchens in addition to central kitchens, and 14 had only centralized food production. The majority of the districts that transported food transported hot (n⫽39) and cold (n⫽48) foods in bulk. Most school districts (n⫽67) operated a centralized warehousing facility. Table 1 summarizes overall emergency preparedness practices/procedures and those related to facilities and equipment, implementation, and staffing. A majority of respondents indicated that their district had established an emergency response team and that the school nutrition department is included as part of this team. However, only approximately half of respondents (37 of 74) have written procedures to ensure safe food during an emergency. Furthermore, respondents stated that the district did have a written emergency preparedness plan that included school nutrition responsibilities, but the plan did not include written procedures for emergency response to natural disasters in 37 of 74 districts, did not include written procedures for responding to a food recall in 47 of 73 districts, and did not include written procedures for food defense in 30 of 74 districts. The mean importance rating (⫾standard deviation) for establishing written procedures for emergencies was deemed very important (4.0⫾0.8). Many implementation practices were related to food defense. Only 25 of 78 respondents require vendors to conduct background checks on delivery personnel. Few respondents require vendors to show photo identification and sign in before making deliveries, even though respondents rated this practice as important. In addition, the majority of respondents do not post a delivery schedule with company and driver information or day and time of anticipated delivery. Slightly more than half stated that employees wear photo identification badges while on school property and rated this as important. 2 analysis (Table 1) showed that practices were more likely to be in place if directors perceived them to be important. Many practices were not implemented in a large percentage of districts, indicating a need to educate directors about the importance of these practices and provide resources to assist them with implementation. Implementation and perceived importance ratings of emergency facilities and equipment in school foodservice operations are presented in Table 2. Only approximately half of respondents with central warehouses (28 of 62) reported having an emergency backup generator, yet they rated having an emergency backup generator as very important. Money was rated between “some barrier” and “barrier,” but not a “critical barrier.” School districts may have funding for such equipment but may not realize the importance of having a generator in case of an emergency. A majority of respondents did not have a safe backup supply of water, yet the importance rating for that was in the important to very important range. Restricted access to storage facilities was rated as important to very im-
December 2007 ● Journal of the AMERICAN DIETETIC ASSOCIATION
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Table 1. Practices and standard operating procedures related to emergency preparedness used in school districts with centralized food production and directors’ ratings of importance (n⫽78) Importance Rating (n)a
Use
District procedures An emergency response team has been established by the district The district includes school nutrition staff as part of the emergency response team The district has written procedures to ensure safe foods during a food recall The district has a formal, written emergency preparedness plan that identifies specific responsibilities for the school nutrition program The district has written procedures to ensure safe food during a natural disaster The district has written procedures to ensure food defense (preventing intentional contamination of food) The district requires all vendors who make deliveries on-site to conduct background checks on delivery personnel Facilities and equipment School foodservice has an adequate, dedicated delivery truck fleet At least a three-day emergency food supply is on-hand at all times An emergency menu is available at all food preparation sites Contracts with roofing, construction, and custodial companies are in place Vendors or community organizations have agreed to supply temporary food storage, ie warehouse or trucks Implementation Food deliveries are checked for signs of tampering Missing foodservice items and other irregularities are investigated immediately School foodservice truck drivers can be contacted directly while making deliveries to sites Central office can determine inventory levels at all sites (including central warehouse, if applicable) Areas with restricted personnel access are protected, ie security guard, keys, etc Food vendor communication procedures are included in the district plan Security guards and/or video cameras are in place in the foodservice facility and perimeter during off hours Vendors must show photo identification and sign in prior to making deliveries A delivery schedule is posted with the name of the company, the driver’s name, and the day and time of the delivery Staffing District has a designated media/lead spokesperson All district staff members have contact phone numbers (cell and land) of all emergency team members accessible at all times District maintains current contact information for all staff members Staff has been designated and responsibilities assigned for emergency preparedness All employees wear photo identification badges while on premises New employee orientation includes training on emergency preparedness Administrative staff has access to employee lockers New employees are placed on day shift initially for increased observation a
I
VI
C
2 Significanceb
MeanⴞSDc
1
10
25
37
*
4.3⫾0.8
0
3
14
25
31
*
4.2⫾0.9
26
0
2
13
32
24
***
4.1⫾0.8
52
22
0
3
17
26
26
*
4.0⫾0.9
37
37
0
2
16
29
23
30
44
0
3
22
23
19
**
3.9⫾0.9
25
45
2
14
21
18
14
**
3.4⫾1.1
66 58 50
11 17 25
2 0 4
3 6 7
19 21 24
31 29 27
18 17 11
*** *** **
3.8⫾0.9 3.8⫾0.9 3.5⫾1.0
57
17
8
6
20
23
11
***
3.3⫾1.2
22
51
11
16
23
11
7
**
2.8⫾1.2
71
5
0
1
23
26
23
71
5
1
1
29
28
14
***
3.7⫾0.8
58
17
2
3
23
27
14
***
3.7⫾0.9
59
18
1
6
27
25
11
61
16
2
4
28
7
9
**
3.5⫾0.9
29
46
1
11
31
18
8
***
3.3⫾0.9
28
48
4
15
22
20
8
*
3.2⫾1.0
17
60
5
16
25
18
5
***
3.0⫾1.0
19
58
6
21
21
15
4
***
2.9⫾1.1
76
0
0
2
14
34
23
62 72
14 5
1 0
4 3
11 15
29 37
27 18
***
4.1⫾0.9 4.0⫾0.8
68 46
8 31
0 1
5 16
16 18
30 25
21 11
*** ***
4.0⫾0.9 3.4⫾1.1
28 32
43 37
2 4
8 18
34 21
17 17
6 4
*** ***
3.3⫾0.9 3.0⫾1.0
30
27
14
10
19
9
0
***
2.4⫾1.1
Yes
No
NI
SI
72
4
0
63
12
47
4.0⫾0.8
4.0⫾0.8
3.6⫾0.9
4.1⫾0.8
A 5-point scale was used for responses, 1⫽not important to 5⫽critical. NI⫽not important; SI⫽somewhat important; I⫽important; VI⫽very important; C⫽critical. tests were used to relate yes/no responses to importance ratings. In all cases where there is a significant 2, school foodservice directors who had practices in place rated them as more important. c SD⫽standard deviation. *P⬍0.05. **P⬍0.01. ***P⬍0.001. b 2
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Table 2. Emergency facilities and equipment available in school districts with centralized foodservice operations and directors’ ratings of importance (n⫽78) Equipment Use
The district and school nutrition computer server is protected from physical damage, ie flooding, fire Generator backups are available for the centralized kitchen School nutrition unit has a safe backup water supply District has fire prevention equipment Communication via long-distance band radios (walkie-talkies) has been established Designated emergency shelters have been identified District has a backup supply of fuel for generators Sanitizer kits are available during emergencies Central kitchen is equipped with emergency lighting Generator backups are available for the central warehouse School nutrition unit can prepare and serve safe food during an electrical outage All access doors to storage facilities are locked and secure at all times Security lights are in operation during evening hours School nutrition unit can prepare and serve safe food during a gas outage Emergency supplies are in place, ie flashlights, tarps, raincoats, batteries Generator backups are available at each school nutrition unit
Importance Rating (n)a
Yes
No
NI
65 28 28 61
12 34 47 14
1 0 1 1
60 55 47 45 39 37
18 19 23 31 20 35
62
SI
I
VI
C
4 7 6 7
8 9 13 14
29 19 25 29
31 22 24 0
1 1 1 0 0 4
7 7 7 6 5 7
16 15 12 19 11 9
26 24 23 23 23 17
23 22 23 23 16 30
16
0
5
18
35
14
52 63
25 13
2 2
5 3
18 24
26 29
21 15
62
15
1
7
17
34
14
47 8
26 68
0 2
9 14
21 24
27 18
14 11
2 Significanceb
MeanⴞSDc
***
4.2⫾0.9 4.0⫾1.0 3.9⫾1.0 3.9⫾1.0
** *** * *
3.9⫾1.0 3.9⫾1.0 3.9⫾1.0 3.9⫾1.0 3.9⫾0.9 3.9⫾1.2 3.8⫾0.8
* **
3.8⫾1.0 3.7⫾0.9 3.7⫾0.9
*
3.7⫾0.9 3.3⫾1.1
a
A 5-point scale was used for responses, 1⫽not important to 5⫽critical. NI⫽not important; SI⫽somewhat important; I⫽important; VI⫽very important; C⫽critical. tests were used to relate yes/no responses to importance ratings. In all cases where there is a significant 2, school foodservice directors who had practices in place rated them as more important. c SD⫽standard deviation. *P⬍0.05. **P⬍0.01. ***P⬍0.001. b 2
portant, but almost one third of the school foodservice directors reported not having all storage facilities secured. Federal food defense recommendations state that this is critical for maintaining a safe food supply (8). There were no barriers to implementing the emergency preparedness policies and procedures that were rated as critically important. The barrier with the highest mean rating was money, followed by lack of equipment, which may be related. However, a lack of knowledge or lack of identifying a need for emergency equipment may explain why more school districts do not have adequate emergency equipment. Time was rated as the third highest barrier. This may be especially true because of recent competing requirements for implementing a school district wellness policy and a school food safety program, both unfunded federal mandates in the Child Nutrition and WIC Reauthorization Act of 2004 (16). Staff not perceiving a need to prepare for emergencies, trucks available for transportation, access to school buildings, and coordination/communication with outside departments were rated as some barrier, but not barriers with a big impact on the department. In regard to training, food safety topics were rated as the most important and were offered most frequently.
This may reflect legislation that requires each school food authority to implement a food safety program that complies with hazard analysis critical control point (HACCP) guidelines established by the US Department of Agriculture (16) by the beginning of the 2006-2007 school year. Emergency preparedness training was provided by 61 of 78 districts. Providing practice drills for emergency response received the lowest mean importance rating, and training was provided by only 33 of 76 districts, even though guidance materials developed for onsite retail foodservice operations encourage practice drills as part of emergency preparedness training programs (2). Emergency topics such as first aid, cardiopulmonary resuscitation, and use of emergency equipment also were areas in which limited training was provided. This study shows that many large, centralized school district foodservice operations do not have written plans, including policies and procedures, for responding to natural disasters and food recalls or for preventing possible food defense violations. These findings are consistent with a study of hospitality executives in which less than one third had written emergency preparedness plans (17). Thus, districts need to develop written emergency preparedness plans specific to school foodservice and use
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those written plans as the basis for employee training. School districts need to consider including food defense best practices in their vendor requirements. The importance of implementing emergency preparedness plans needs to be stressed with school foodservice personnel. Limitations of this study include a low response rate (39%) and lack of generalizability beyond school districts in the United States that use central kitchens for food warehousing, production, and delivery. Future studies should examine emergency preparedness practices, barriers, and employee training in schools that do onsite production as well as other types of foodservice operations, such as hospitals and long-term care facilities. CONCLUSIONS Many best practices have been identified in this study that can be used in any onsite retail foodservice (schools, hospitals, long-term care, assisted living, colleges and universities, and child care) to ensure readiness in case of an emergency and to prevent emergencies, as in the case of food defense practices. These emergency preparedness practices can be used by foodservice directors in any onsite retail foodservice environment as a self-assessment checklist for evaluating their operations and developing an emergency preparedness plan. Although many guidance materials are available from a variety of sources, there is a need for samples that can be adapted and used in foodservice. For example, sample written standard operating procedures that should be included as part of an emergency preparedness plan are needed. These standard operating procedures could form the basis for developing training materials and programs. Further, these standard operating procedures could be made available on various Internet sites for easy access by foodservice directors and presented in a format that could be easily changed to meet the needs of a specific foodservice operation. Perceived barriers to implementing procedures identified in this study may also be barriers in other environments. Foodservice directors need to explore ways to overcome barriers to ensure preparation for emergencies. Sharing of standard operating procedures, training programs, and other resources may be one way to minimize time limitations. Limited money and lack of emergency equipment were the two barriers rated as most critical. Foodservice directors need to evaluate equipment availability, and budget to purchase needed equipment. Routine training represents an important best practice in any foodservice operation, especially in those with high employee turnover. This study indicated that during the previous year fewer than half of the school districts did training on cardiopulmonary resuscitation, use of emergency equipment, and practice drills. Use of practice drills to simulate an actual emergency may be an effective means of preparing employees for emergencies. Funding for the National Food Service Management Institute has been provided with Federal funds from the US Department of Agriculture, Food and Nutrition Services, and the University of Mississippi. The contents of this publication do not necessarily reflect the views or policies of the University of Mississippi or the US Department of
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Agriculture, nor does mention of trade names, commercial products, or organizations imply endorsement by the US government. References 1. Carmona RH. Dietitians play important role in emergency preparedness. J Am Diet Assoc. 2006;106:1321. 2. National Food Service Management Institute. Emergency readiness plan: A guide for the school foodservice operation. University, MS: National Food Service Management Institute; 2003. Available at: http://www.nfsmi.org/Information/e-readiness.html. Accessed August 1, 2006. 3. US Department of Agriculture, Food Safety and Inspection Service. Fact Sheet: Keeping food safe during an emergency. Washington, DC: US Food Safety Inspection Service; 2004. Available at: http://www. fsis.usda.gov/PDF/Keeping_Food_Safe_During_An_Emergency.pdf. Accessed April 6, 2006. 4. US Department of Agriculture, Food Safety and Inspection Service. Guidelines for retail and foodservice establishments affected by natural or other disasters. Washington, DC: US Department of Agriculture, Food Safety Inspection Service; 2005. Available at: http://www. fsis.usda.gov/PDF/Fsis_Fda_Retail_Reopening.pdf. Accessed August 1, 2006. 5. US Food and Drug Administration, US Department of Health and Human Services. Guidance for industry: Product recalls including removals and corrections. Rockville, MD: US Food and Drug Administration, US Department of Health and Human Services, Office of Regulatory Affairs, Office of Enforcement; 2003. Available at: http:// www.fda.gov/ora/compliance_ref/recalls/ggp_recall.htm. Accessed August 1, 2006. 6. National Food Service Management Institute. Responding to a food recall. University, MS: National Food Service Management Institute; 2002. Available at: http://www.nfsmi.org/Information/recallmanual. pdf. Accessed August 3, 2006. 7. Golan E, Krissoff B, Kuchler F, Calvin L, Nelson K, Price G. Traceability in the US food supply: Economic theory and industry studies. Washington, DC: Economic Research Service, US Department of Agriculture; 2004. Agricultural Economic Report No. 830. Available at: http://www.ers.usda.gov/publications/aer830. Accessed March 7, 2006. 8. US Department of Agriculture, Food and Nutrition Service. A biosecurity checklist for school foodservice programs: Developing a biosecurity management plan. Washington, DC: US Department of Agriculture, Food and Nutrition Service; 2004. Available at: http:// healthymeals.nal.usda.gov/hsmrs/biosecurity.pdf. Accessed March 7, 2006. 9. US Food and Drug Administration, US Department of Health and Human Services. Retail food stores and food service establishments: Food security preventive measures guidance. College Park, MD: US Food and Drug Administration, US Department of Health and Human Services; 2004. 10. US Department of Agriculture, Food Safety and Inspection Service. Industry self-assessment checklist for food security. US Department of Agriculture, Food Safety and Inspection Service. 2005. Available at: http://www.fsis.usda.gov/PDF/Self_Assessment_Checklist_Food_ Security.pdf. Accessed August 3, 2006. 11. US Department of Health and Human Services, US Food and Drug Administration, Center for Food Safety and Applied Nutrition. Food safety and security: Operational risk management systems approach. Washington, DC: US Department of Health and Human Services, US Food and Drug Administration, Center for Food Safety and Applied Nutrition; 2001. 12. Abatemarco A, Beckley J, Borjan M, Robson M. Assessing and improving bioterrorism preparedness among first responders: A pilot study. J Environ Health. 2007;69:16-22. 13. Currier M, King DS, Wofford MR, Daniel BJ, deShazo R. A Katrina experience: Lessons learned. Am J Med. 2006;119:986-992. 14. Luband C. Emergency preparedness for hospitals and the healthcare marketplace. Admin Law Rev. 2006;58:575-585. 15. Hyer K, Brown LM, Berman A, Polivka-West L. Establishing and refining hurricane response systems for long-term care facilities. Health Aff. 2006;25:407-411. 16. Child Nutrition and WIC Reauthorization Act of 2004, PL No. 108265, § 204, 118 Stat. 204; 2004. 17. Drabek TE. Disaster planning and response by tourist business executives. Cornell Hotel Rest Adminis Quarterly. 1995;36:86-96.
Emergency Preparedness Needs Assessment of Centralized School Foodservice and Warehousing Operations CYNDIE STORY, MEd, RD; JEANNIE SNEED, PhD, RD; CHARLOTTE B. OAKLEY, PhD, RD, FADA; THERESA STRETCH, MS, RD
ABSTRACT Managers of onsite retail foodservice operations, particularly those in centralized school foodservice operations, are called on to provide meals during emergencies, yet there is a paucity of research on their readiness to handle emergencies. Qualitative research and a cross-sectional survey design were used to conduct a needs assessment for emergency preparedness (emergency readiness, food recalls, and food defense) in centralized school foodservice operations, including warehousing. An open-ended written questionnaire was mailed to eight foodservice directors, and responses were used to develop a written questionnaire that was mailed to school foodservice directors in 200 districts identified as having centralized food production and warehousing. Directors from 78 districts responded (39% response rate). Most districts (n⫽72) had an emergency response team, and foodservice was included as part of 63 of those teams. Not all districts had written procedures for food recalls (47 of 73), natural disasters (37 of 74), or food defense (30 of 74). Barriers to implementing emergency preparedness policies and procedures included limited money, emergency equipment, and time. Most current training related to food safety with little training related to emergency preparedness. Training on the emergency preparedness plan was done in 61 of 78 districts. Training on emergency procedures was done by less than half of the districts during the previous year. This study identified best practices related to emergency preparedness that can be implemented in onsite retail foodservice operations. Results indicate a need to emphasize emergency preparedness, develop
C. Story is a consultant, Culinary Solution Centers, LLC, Jacksonville, FL. J. Sneed is a consultant, Sneed Consulting, Stillwater, OK; at the time of the study, she was a professor, Iowa State University, Ames. C. B. Oakley is executive director and T. Stretch is a food and nutrition specialist, National Food Service Management Institute, University, MS. Address correspondence to: Jeannie Sneed, PhD, RD, Sneed Consulting, PO Box 1026, Stillwater, OK 74076. E-mail: [email protected] Copyright © 2007 by the American Dietetic Association. 0002-8223/07/10712-0006$32.00/0 doi: 10.1016/j.jada.2007.09.007
2100
Journal of the AMERICAN DIETETIC ASSOCIATION
written standard operating procedures, and train employees to be prepared to respond to emergencies. J Am Diet Assoc. 2007;107:2100-2104.
I
n 2006, the United States Surgeon General stated that “our nation is constantly under threats to our public health” from natural and man-made disasters and emphasized the need for food and nutrition professionals to be part of the first line of defense to improve emergency readiness in local communities (1). Numerous government documents guide foodservice operators on emergency preparedness, specifically emergency readiness (2-4), chain of custody and food recalls (5-7), and food defense (8-11). Research has addressed preparation of first responders’ use of respiratory protection (12), management of medical needs after Hurricane Katrina (13), and use of emergency preparedness drills in hospitals (14) and long-term care facilities (15), yet there is a paucity of research related to onsite retail foodservice operations. Centralized school foodservice operations may be a significant resource for food during an emergency situation because they are able to prepare and transport large amounts of food throughout a community. Due to the large number of students served by centralized foodservice operations, they may be of greater concern and at higher risk for breaches to food security than individual schools. Thus, the purpose of this study was to conduct an emergency preparedness needs assessment for centralized school foodservice operations, including warehousing and distribution. Specific objectives were: (a) to identify emergency preparedness policies and standard operating procedures currently used in centralized school foodservice operations; (b) to identify barriers to implementing emergency preparedness policies and standard operating procedures; and (c) to determine frequency and type of emergency preparedness training and training needs of staff in centralized foodservice operations, including staff responsible for distribution/shipping. METHODS Study Design and Sample Qualitative research and a cross-sectional survey design were used. The study sample included school foodservice directors in the 200 largest school districts in the United States identified as having centralized foodservice operations or a warehouse distribution center. The National Food Service Management Institute has developed a database of these school districts and provided mailing labels.
© 2007 by the American Dietetic Association
Questionnaire Questionnaire Development. A written questionnaire was used to gather opinions from eight experienced district school foodservice directors. Seven open-ended questions addressed current practices that support emergency preparedness, practices that need to be established to ensure that a centralized school foodservice operation is adequately prepared to respond to an emergency, facilities and equipment needed to respond to an emergency, policies and standard operating procedures related to emergency preparedness that are in place in their operations, barriers to emergency preparedness, emergency preparedness trainings attended, and type of staff training needed. This round of questioning was the basis for questionnaire development and provided content validity. Research Questionnaire. A five-part questionnaire was developed. Part 1 included five questions to determine characteristics of the school district and foodservice operation, including district participation in the federal child nutrition program, types of foodservice operations used in the district (ie, onsite kitchens, centralized kitchen serving both offsite and onsite, and centralized kitchen with no onsite service), how food is transported (hot/cold; preplated/bulk), district enrollment, and use of a centralized warehousing operation. Part 2 of the questionnaire examined practices and standard operating procedures in school districts. Items were related to district procedures, facilities and equipment, implementation, and staffing. For each item, respondents were asked to indicate if their organizations had this practice or policy in place and to rate its importance using a 5-point scale: not important, somewhat important, important, very important, or critical. Part 3 included seven potential barriers to implementing emergency preparedness policies and procedures. Respondents were asked to rate each barrier using a 4-point scale: not a barrier; some barrier but not a big impact; barrier that needs to be addressed; or critical barrier. Part 4 included 16 items related to facility and equipment requirements. Respondents were asked to indicate (yes/no) if their organization had each of the items in place and rate the item’s importance using the same scale as in Part 2. Part 5 included 18 potential areas for training. Respondents were asked to indicate (yes/no) whether training on the topic had been provided within the past year and to rate the importance of training using the importance scale used in Part 2. After each part, space was provided for respondents to write in other emergency preparedness concerns. The questionnaire was reviewed for clarity and content validity by three researchers and three school foodservice directors. The Iowa State University Institutional Review Board’s Human Subjects Review Committee approved the questionnaire and study protocol before data collection. Data Collection. A cover letter, questionnaire, and postagepaid return envelope were mailed to each school foodservice director in the sample. Four weeks after the initial mailing, researchers mailed a follow-up letter, survey, and postage-paid return envelope to encourage response. Data Analysis. Survey data were compiled using SPSS-X (version 13, 2005, SPSS Inc, Chicago, IL). Descriptive
statistics (ie, frequencies, means, and standard deviations) were calculated and crosstabs with 2 examined relationships between current implementation of practices and importance ratings. RESULTS AND DISCUSSION Foodservice directors from 78 school districts responded (39% response rate). Most districts had onsite kitchens in addition to central kitchens, and 14 had only centralized food production. The majority of the districts that transported food transported hot (n⫽39) and cold (n⫽48) foods in bulk. Most school districts (n⫽67) operated a centralized warehousing facility. Table 1 summarizes overall emergency preparedness practices/procedures and those related to facilities and equipment, implementation, and staffing. A majority of respondents indicated that their district had established an emergency response team and that the school nutrition department is included as part of this team. However, only approximately half of respondents (37 of 74) have written procedures to ensure safe food during an emergency. Furthermore, respondents stated that the district did have a written emergency preparedness plan that included school nutrition responsibilities, but the plan did not include written procedures for emergency response to natural disasters in 37 of 74 districts, did not include written procedures for responding to a food recall in 47 of 73 districts, and did not include written procedures for food defense in 30 of 74 districts. The mean importance rating (⫾standard deviation) for establishing written procedures for emergencies was deemed very important (4.0⫾0.8). Many implementation practices were related to food defense. Only 25 of 78 respondents require vendors to conduct background checks on delivery personnel. Few respondents require vendors to show photo identification and sign in before making deliveries, even though respondents rated this practice as important. In addition, the majority of respondents do not post a delivery schedule with company and driver information or day and time of anticipated delivery. Slightly more than half stated that employees wear photo identification badges while on school property and rated this as important. 2 analysis (Table 1) showed that practices were more likely to be in place if directors perceived them to be important. Many practices were not implemented in a large percentage of districts, indicating a need to educate directors about the importance of these practices and provide resources to assist them with implementation. Implementation and perceived importance ratings of emergency facilities and equipment in school foodservice operations are presented in Table 2. Only approximately half of respondents with central warehouses (28 of 62) reported having an emergency backup generator, yet they rated having an emergency backup generator as very important. Money was rated between “some barrier” and “barrier,” but not a “critical barrier.” School districts may have funding for such equipment but may not realize the importance of having a generator in case of an emergency. A majority of respondents did not have a safe backup supply of water, yet the importance rating for that was in the important to very important range. Restricted access to storage facilities was rated as important to very im-
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Table 1. Practices and standard operating procedures related to emergency preparedness used in school districts with centralized food production and directors’ ratings of importance (n⫽78) Importance Rating (n)a
Use
District procedures An emergency response team has been established by the district The district includes school nutrition staff as part of the emergency response team The district has written procedures to ensure safe foods during a food recall The district has a formal, written emergency preparedness plan that identifies specific responsibilities for the school nutrition program The district has written procedures to ensure safe food during a natural disaster The district has written procedures to ensure food defense (preventing intentional contamination of food) The district requires all vendors who make deliveries on-site to conduct background checks on delivery personnel Facilities and equipment School foodservice has an adequate, dedicated delivery truck fleet At least a three-day emergency food supply is on-hand at all times An emergency menu is available at all food preparation sites Contracts with roofing, construction, and custodial companies are in place Vendors or community organizations have agreed to supply temporary food storage, ie warehouse or trucks Implementation Food deliveries are checked for signs of tampering Missing foodservice items and other irregularities are investigated immediately School foodservice truck drivers can be contacted directly while making deliveries to sites Central office can determine inventory levels at all sites (including central warehouse, if applicable) Areas with restricted personnel access are protected, ie security guard, keys, etc Food vendor communication procedures are included in the district plan Security guards and/or video cameras are in place in the foodservice facility and perimeter during off hours Vendors must show photo identification and sign in prior to making deliveries A delivery schedule is posted with the name of the company, the driver’s name, and the day and time of the delivery Staffing District has a designated media/lead spokesperson All district staff members have contact phone numbers (cell and land) of all emergency team members accessible at all times District maintains current contact information for all staff members Staff has been designated and responsibilities assigned for emergency preparedness All employees wear photo identification badges while on premises New employee orientation includes training on emergency preparedness Administrative staff has access to employee lockers New employees are placed on day shift initially for increased observation a
I
VI
C
2 Significanceb
MeanⴞSDc
1
10
25
37
*
4.3⫾0.8
0
3
14
25
31
*
4.2⫾0.9
26
0
2
13
32
24
***
4.1⫾0.8
52
22
0
3
17
26
26
*
4.0⫾0.9
37
37
0
2
16
29
23
30
44
0
3
22
23
19
**
3.9⫾0.9
25
45
2
14
21
18
14
**
3.4⫾1.1
66 58 50
11 17 25
2 0 4
3 6 7
19 21 24
31 29 27
18 17 11
*** *** **
3.8⫾0.9 3.8⫾0.9 3.5⫾1.0
57
17
8
6
20
23
11
***
3.3⫾1.2
22
51
11
16
23
11
7
**
2.8⫾1.2
71
5
0
1
23
26
23
71
5
1
1
29
28
14
***
3.7⫾0.8
58
17
2
3
23
27
14
***
3.7⫾0.9
59
18
1
6
27
25
11
61
16
2
4
28
7
9
**
3.5⫾0.9
29
46
1
11
31
18
8
***
3.3⫾0.9
28
48
4
15
22
20
8
*
3.2⫾1.0
17
60
5
16
25
18
5
***
3.0⫾1.0
19
58
6
21
21
15
4
***
2.9⫾1.1
76
0
0
2
14
34
23
62 72
14 5
1 0
4 3
11 15
29 37
27 18
***
4.1⫾0.9 4.0⫾0.8
68 46
8 31
0 1
5 16
16 18
30 25
21 11
*** ***
4.0⫾0.9 3.4⫾1.1
28 32
43 37
2 4
8 18
34 21
17 17
6 4
*** ***
3.3⫾0.9 3.0⫾1.0
30
27
14
10
19
9
0
***
2.4⫾1.1
Yes
No
NI
SI
72
4
0
63
12
47
4.0⫾0.8
4.0⫾0.8
3.6⫾0.9
4.1⫾0.8
A 5-point scale was used for responses, 1⫽not important to 5⫽critical. NI⫽not important; SI⫽somewhat important; I⫽important; VI⫽very important; C⫽critical. tests were used to relate yes/no responses to importance ratings. In all cases where there is a significant 2, school foodservice directors who had practices in place rated them as more important. c SD⫽standard deviation. *P⬍0.05. **P⬍0.01. ***P⬍0.001. b 2
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Table 2. Emergency facilities and equipment available in school districts with centralized foodservice operations and directors’ ratings of importance (n⫽78) Equipment Use
The district and school nutrition computer server is protected from physical damage, ie flooding, fire Generator backups are available for the centralized kitchen School nutrition unit has a safe backup water supply District has fire prevention equipment Communication via long-distance band radios (walkie-talkies) has been established Designated emergency shelters have been identified District has a backup supply of fuel for generators Sanitizer kits are available during emergencies Central kitchen is equipped with emergency lighting Generator backups are available for the central warehouse School nutrition unit can prepare and serve safe food during an electrical outage All access doors to storage facilities are locked and secure at all times Security lights are in operation during evening hours School nutrition unit can prepare and serve safe food during a gas outage Emergency supplies are in place, ie flashlights, tarps, raincoats, batteries Generator backups are available at each school nutrition unit
Importance Rating (n)a
Yes
No
NI
65 28 28 61
12 34 47 14
1 0 1 1
60 55 47 45 39 37
18 19 23 31 20 35
62
SI
I
VI
C
4 7 6 7
8 9 13 14
29 19 25 29
31 22 24 0
1 1 1 0 0 4
7 7 7 6 5 7
16 15 12 19 11 9
26 24 23 23 23 17
23 22 23 23 16 30
16
0
5
18
35
14
52 63
25 13
2 2
5 3
18 24
26 29
21 15
62
15
1
7
17
34
14
47 8
26 68
0 2
9 14
21 24
27 18
14 11
2 Significanceb
MeanⴞSDc
***
4.2⫾0.9 4.0⫾1.0 3.9⫾1.0 3.9⫾1.0
** *** * *
3.9⫾1.0 3.9⫾1.0 3.9⫾1.0 3.9⫾1.0 3.9⫾0.9 3.9⫾1.2 3.8⫾0.8
* **
3.8⫾1.0 3.7⫾0.9 3.7⫾0.9
*
3.7⫾0.9 3.3⫾1.1
a
A 5-point scale was used for responses, 1⫽not important to 5⫽critical. NI⫽not important; SI⫽somewhat important; I⫽important; VI⫽very important; C⫽critical. tests were used to relate yes/no responses to importance ratings. In all cases where there is a significant 2, school foodservice directors who had practices in place rated them as more important. c SD⫽standard deviation. *P⬍0.05. **P⬍0.01. ***P⬍0.001. b 2
portant, but almost one third of the school foodservice directors reported not having all storage facilities secured. Federal food defense recommendations state that this is critical for maintaining a safe food supply (8). There were no barriers to implementing the emergency preparedness policies and procedures that were rated as critically important. The barrier with the highest mean rating was money, followed by lack of equipment, which may be related. However, a lack of knowledge or lack of identifying a need for emergency equipment may explain why more school districts do not have adequate emergency equipment. Time was rated as the third highest barrier. This may be especially true because of recent competing requirements for implementing a school district wellness policy and a school food safety program, both unfunded federal mandates in the Child Nutrition and WIC Reauthorization Act of 2004 (16). Staff not perceiving a need to prepare for emergencies, trucks available for transportation, access to school buildings, and coordination/communication with outside departments were rated as some barrier, but not barriers with a big impact on the department. In regard to training, food safety topics were rated as the most important and were offered most frequently.
This may reflect legislation that requires each school food authority to implement a food safety program that complies with hazard analysis critical control point (HACCP) guidelines established by the US Department of Agriculture (16) by the beginning of the 2006-2007 school year. Emergency preparedness training was provided by 61 of 78 districts. Providing practice drills for emergency response received the lowest mean importance rating, and training was provided by only 33 of 76 districts, even though guidance materials developed for onsite retail foodservice operations encourage practice drills as part of emergency preparedness training programs (2). Emergency topics such as first aid, cardiopulmonary resuscitation, and use of emergency equipment also were areas in which limited training was provided. This study shows that many large, centralized school district foodservice operations do not have written plans, including policies and procedures, for responding to natural disasters and food recalls or for preventing possible food defense violations. These findings are consistent with a study of hospitality executives in which less than one third had written emergency preparedness plans (17). Thus, districts need to develop written emergency preparedness plans specific to school foodservice and use
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those written plans as the basis for employee training. School districts need to consider including food defense best practices in their vendor requirements. The importance of implementing emergency preparedness plans needs to be stressed with school foodservice personnel. Limitations of this study include a low response rate (39%) and lack of generalizability beyond school districts in the United States that use central kitchens for food warehousing, production, and delivery. Future studies should examine emergency preparedness practices, barriers, and employee training in schools that do onsite production as well as other types of foodservice operations, such as hospitals and long-term care facilities. CONCLUSIONS Many best practices have been identified in this study that can be used in any onsite retail foodservice (schools, hospitals, long-term care, assisted living, colleges and universities, and child care) to ensure readiness in case of an emergency and to prevent emergencies, as in the case of food defense practices. These emergency preparedness practices can be used by foodservice directors in any onsite retail foodservice environment as a self-assessment checklist for evaluating their operations and developing an emergency preparedness plan. Although many guidance materials are available from a variety of sources, there is a need for samples that can be adapted and used in foodservice. For example, sample written standard operating procedures that should be included as part of an emergency preparedness plan are needed. These standard operating procedures could form the basis for developing training materials and programs. Further, these standard operating procedures could be made available on various Internet sites for easy access by foodservice directors and presented in a format that could be easily changed to meet the needs of a specific foodservice operation. Perceived barriers to implementing procedures identified in this study may also be barriers in other environments. Foodservice directors need to explore ways to overcome barriers to ensure preparation for emergencies. Sharing of standard operating procedures, training programs, and other resources may be one way to minimize time limitations. Limited money and lack of emergency equipment were the two barriers rated as most critical. Foodservice directors need to evaluate equipment availability, and budget to purchase needed equipment. Routine training represents an important best practice in any foodservice operation, especially in those with high employee turnover. This study indicated that during the previous year fewer than half of the school districts did training on cardiopulmonary resuscitation, use of emergency equipment, and practice drills. Use of practice drills to simulate an actual emergency may be an effective means of preparing employees for emergencies. Funding for the National Food Service Management Institute has been provided with Federal funds from the US Department of Agriculture, Food and Nutrition Services, and the University of Mississippi. The contents of this publication do not necessarily reflect the views or policies of the University of Mississippi or the US Department of
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Agriculture, nor does mention of trade names, commercial products, or organizations imply endorsement by the US government. References 1. Carmona RH. Dietitians play important role in emergency preparedness. J Am Diet Assoc. 2006;106:1321. 2. National Food Service Management Institute. Emergency readiness plan: A guide for the school foodservice operation. University, MS: National Food Service Management Institute; 2003. Available at: http://www.nfsmi.org/Information/e-readiness.html. Accessed August 1, 2006. 3. US Department of Agriculture, Food Safety and Inspection Service. Fact Sheet: Keeping food safe during an emergency. Washington, DC: US Food Safety Inspection Service; 2004. Available at: http://www. fsis.usda.gov/PDF/Keeping_Food_Safe_During_An_Emergency.pdf. Accessed April 6, 2006. 4. US Department of Agriculture, Food Safety and Inspection Service. Guidelines for retail and foodservice establishments affected by natural or other disasters. Washington, DC: US Department of Agriculture, Food Safety Inspection Service; 2005. Available at: http://www. fsis.usda.gov/PDF/Fsis_Fda_Retail_Reopening.pdf. Accessed August 1, 2006. 5. US Food and Drug Administration, US Department of Health and Human Services. Guidance for industry: Product recalls including removals and corrections. Rockville, MD: US Food and Drug Administration, US Department of Health and Human Services, Office of Regulatory Affairs, Office of Enforcement; 2003. Available at: http:// www.fda.gov/ora/compliance_ref/recalls/ggp_recall.htm. Accessed August 1, 2006. 6. National Food Service Management Institute. Responding to a food recall. University, MS: National Food Service Management Institute; 2002. Available at: http://www.nfsmi.org/Information/recallmanual. pdf. Accessed August 3, 2006. 7. Golan E, Krissoff B, Kuchler F, Calvin L, Nelson K, Price G. Traceability in the US food supply: Economic theory and industry studies. Washington, DC: Economic Research Service, US Department of Agriculture; 2004. Agricultural Economic Report No. 830. Available at: http://www.ers.usda.gov/publications/aer830. Accessed March 7, 2006. 8. US Department of Agriculture, Food and Nutrition Service. A biosecurity checklist for school foodservice programs: Developing a biosecurity management plan. Washington, DC: US Department of Agriculture, Food and Nutrition Service; 2004. Available at: http:// healthymeals.nal.usda.gov/hsmrs/biosecurity.pdf. Accessed March 7, 2006. 9. US Food and Drug Administration, US Department of Health and Human Services. Retail food stores and food service establishments: Food security preventive measures guidance. College Park, MD: US Food and Drug Administration, US Department of Health and Human Services; 2004. 10. US Department of Agriculture, Food Safety and Inspection Service. Industry self-assessment checklist for food security. US Department of Agriculture, Food Safety and Inspection Service. 2005. Available at: http://www.fsis.usda.gov/PDF/Self_Assessment_Checklist_Food_ Security.pdf. Accessed August 3, 2006. 11. US Department of Health and Human Services, US Food and Drug Administration, Center for Food Safety and Applied Nutrition. Food safety and security: Operational risk management systems approach. Washington, DC: US Department of Health and Human Services, US Food and Drug Administration, Center for Food Safety and Applied Nutrition; 2001. 12. Abatemarco A, Beckley J, Borjan M, Robson M. Assessing and improving bioterrorism preparedness among first responders: A pilot study. J Environ Health. 2007;69:16-22. 13. Currier M, King DS, Wofford MR, Daniel BJ, deShazo R. A Katrina experience: Lessons learned. Am J Med. 2006;119:986-992. 14. Luband C. Emergency preparedness for hospitals and the healthcare marketplace. Admin Law Rev. 2006;58:575-585. 15. Hyer K, Brown LM, Berman A, Polivka-West L. Establishing and refining hurricane response systems for long-term care facilities. Health Aff. 2006;25:407-411. 16. Child Nutrition and WIC Reauthorization Act of 2004, PL No. 108265, § 204, 118 Stat. 204; 2004. 17. Drabek TE. Disaster planning and response by tourist business executives. Cornell Hotel Rest Adminis Quarterly. 1995;36:86-96.