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A Recipe for Hand Hygiene Process Control
How to structure a handwashing program that sustains safe food handling for the long haul
by Jim Mann
Process control drives almost all food safety measures, with the exception of handwashing and hand hygiene. These remain a frontier without meaningful, measureable, and manageable standards.
Operators are often content for hand hygiene to be covered in their FDA-promulgated good manufacturing practices, seeing little need for specific standards to drive enhanced hand hygiene. The FDA’s Model Food Code has been unable to provide guidance for a situation in which behavioral science is key to compliance. Codes and operational standards work best for physical measurements like temperature control or chemical factors such as pH. Logs can be easily maintained and monitored.
Solving handwashing issues in the food industry is not about knowledge, training, products, or equipment. It is all about linking best practices in a structured, sustainable solution.
Risks of Poor Hygiene
Poor hand hygiene is the most frequently mentioned contributing factor in outbreak reporting. Juxtaposing this risk with the advice of the Centers for Disease Control and Prevention (CDC) highlights the risk reduction potential in pursuing improved hand hygiene process control:
“Handwashing is the single most important means of preventing the spread of infection.”
The food processing industry has made amazing advances when it comes to minimizing dangerous line-worker touches. Now the risk of hand contamination comes mainly from processing speed, batch size, and food prices.
Food service continues, however, to involve many hands in the race to serve tasty, safe food. In fact, as chefs recognize the value of visuals to a satisfying dish, more hands become involved. Garnishes and plating priorities often require the skill and touch of a clean bare hand. The challenge now becomes serving food that is tasty and artful but is still safe to eat.
Measuring risk is an exercise in approximation; the fact that it is not a true science must not prevent common-sense interventions.
The media has a strong influence on operator risk assessment and priorities. Sprouts. Cantaloupes. FDA Food Safety Modernization Act. Based on the headlines of the past year, one could easily put hand hygiene improvements on the back burner.
Shielding food safety from political partialities is impossible. From neighborhood issues to United Nations priorities, food safety permeates and affects our reality—from farms to the forks of the world. The recurring stories of 48 million foodborne illness-stricken Americans, the 128,000 hospitalizations, and the 3,000 deaths that occur each year are eclipsed by popularly provocative politics.
If the media were risk-based, poor hand hygiene would likely dominate, and we would be celebrating the comparative safety levels of our nation’s food processors.
A Range of Risks
Operators have a range of responsibilities, including moral, financial, and legal, when it comes to minimizing restaurant-acquired illness. And, while foodborne illness is a major part of this risk category, it is important not to minimize the risk of other illnesses that could be acquired by patrons of a restaurant, perhaps from a contaminated restroom or the table of a pathogenic patron.
The focus on food preparation by the FDA and its army of 30,000-plus inspectors tends to skew the restaurant’s risk reduction actions to the kitchen and largely to those tasks that can be easily measured during a one-hour visit. Current food temperatures, from refrigerated storage to prep, and hot-holding numbers are priorities.
Looking at risk from a scientific perspective causes food safety auditors to include restrooms, especially those that are used by the public and staff. Many outbreaks arise from service areas where the public introduces pathogens, particularly norovirus, the dominant foodborne pathogen (58% reported in CDC 2011 Estimate.www.cdc.gov/Features/dsFoodborneEstimates/).
Poor hand hygiene is the most frequently mentioned contributing factor in outbreak reporting. The food processing industry has made amazing advances when it comes to minimizing dangerous line worker touches. Now the risk of hand contamination comes mainly from processing speed, batch size, and food prices.
And what about the flu and the common cold? These are not monitored like foodborne illnesses, nor will operators be sued for spreading them. The payoff for restaurants building barriers to these most common afflictions is reduced staff absenteeism. Out-front programs that include hand sanitizers for all to use, together with an increased focus on high-touch surfaces, protect employee health as well as that of customers.
Hand hygiene through the legal prism provides the clearest and most measurable view of risk. Technology increasingly ties the ill patron to the restaurant. More people looking for foodborne outbreaks and better diagnostics at hospital ERs quickly make the connections. The legal principle of strict liability kicks in, and the operator is paying out almost every time. Owners then hope to avoid the negligence factor, a multiplier of damages.
Team Risk Assessment
Process control of any type requires a multidisciplinary approach. This is especially important for enhancing hand hygiene standards. Quality assurance commonly raises internal awareness of issues and often identifies solutions.
The flywheel of conventional thinking takes over and traditional barriers are shored up and defended. Here is where the passion and commitment of the team leader are put to the test. If operations, finance, risk management, and training join in, the solution will be free to grow and be implemented on a timely basis, delivering years of continuous improvement.
A hand hygiene process control enhancement project must be built with the same rigor of a new menu item or staff uniform change. It amounts to a mini-business plan listing objectives, required resources, payback, a timetable that includes clear and agreed milestones, and feedback systems.
Before the first meeting, the project champion is well advised to informally recruit key believers after gaining support from his or her boss. Try to keep the group small—never more than seven people. When working in groups with more than seven members, the long silence between contributions in group work sparks distractions, according to corporate effectiveness experts at Synecticsworld, based in Cambridge, Mass. Each member of this cross-functional team should clearly understand his or her role and be aware that this is a temporary coalition.
Safe Level Standards
The first meeting of the hand hygiene risk reduction team should attempt to gain consensus and verbalize the company’s need and its own internal vocabulary of risks: What is the situation now and what would we like it to be? An initial estimated timetable for the path forward is helpful at this stage.
Employee effectiveness in handwashing is a good place to start. Here a standard can be set using a simple tracer method called ProGrade, which uses a lotion sensitive to long-wave ultraviolet light (skin-safe range), sometimes referred to as black light. (ProGrade is an acronym for Proficiency Grading.)
The tracer is rubbed in like a hand lotion, ensuring full coverage. When it is washed off, hands are placed under UV light, where any missed areas emit a blue glow. This information is scored and placed in the employee’s file—usually after a few trips back to the hand sink, as the employee learns more about his or her own skin condition and the importance of a thorough hand wash.
This method highlights the need to wash for 15 seconds as the Model Food Code suggests and demonstrates why specified nail length must be maintained. It also provides a foundation to objectively implement the jewelry policy.
Our hand hygiene team now meets around a convenient hand sink with a minimum flow of 2 gallons per minute, common to professional kitchens (plumbing code). Everyone tries the method, usually multiple times, and completes rounds of self-scoring. One point is taken for spots missed and five points for a skipped area. A preliminary standard is then agreed upon. The team now has its first handwashing standard.
Day One ServeReady Training Log
To establish handwashing as a mission-critical qualification for employment, it is helpful to conduct the ProGrade protocol on day one and keep a log. This can be shared with auditors and health department inspectors to show that everyone on the floor has had at least minimal handwashing training. Records can be entered into personnel files to further establish hand hygiene as an operational priority.
Establishing Handwashing Frequency
Restaurants are wary about setting frequency minimums until they realize it is the best way to motivate shift managers and their teams. This realization is seeded during another meeting of the hand hygiene team, at which there is commonly a general concession that whatever isn’t measured is done last, if at all.
A list of actions requiring a hand wash is created based on the FDA’s Model Food Code and passed around to be filled in independently. Each team member shares and defends an opinion on average number of hand washes expected per shift. After dividing that number by the hours, you now have an ideal number for hand washes per employee hour.
A preliminary standard is agreed upon and a pilot study is put in motion to capture the actual level. Inexpensive soap dispensers equipped with counting mechanisms are available. The best one has a patented system that captures multiple “pushes” as a single hand wash. Each kitchen hand sink station is equipped with the counting soap dispensers, preferably numbered in order to connect each work group to its most frequently used hand sink.
These units are set to zero at the start of the restaurant’s calendar week, typically the day after a pay period. At the end of that interval, when all the staff hours are readily available, readings are taken at each, then added together and divided by the total man-hours worked, providing an index of actual hand washes per employee hour.
A baseline is established over three reporting cycles, usually three weeks. This commonly produces a significant performance gap and sets the foundation for further actions with numeric goals.
Set Conditions for Success
A walk-through assessment of the space during peak periods is done at this stage. Blocked hand sinks, inefficiencies, and bottlenecks are noted. These “conditions for success” can be reviewed to make it easier for the food worker to do the right thing.
Touch-free faucets facilitate frequent and fast handwashing. Consider adding these to the project, starting with the busiest hand sink and adding the others as budgets permit.
Along with hand sink design choice, location can improve compliance. Too often, original food flows are lost to multiple menu changes over the years, resulting in the wrong sink being located nearest to a high-need hand wash location. Melons are being scrubbed while hand washers wait at this station, well labeled For Handwashing Only.
Hand soap criteria change when staff starts washing more often. Soap must not smell like a harsh chemical. It must be effective, fast rinsing, and kind to the skin. No-touch electronic dispensing is preferred.
Paper toweling, like soap, is no longer a decision weighted by value engineering and purchasing. Paper that is highly absorbent and strong when wet top the specifications. Designs that aid friction improve speed and attract frequent users.
Air dryers are sometimes specified to help keep premises, especially restrooms, clean and uncluttered. Hand drying with disposable paper toweling is not only faster, it is also preferred by the public and is more effective. The friction added by the paper towel typically adds a one log reduction of pathogens. Giving up this risk-reducing level of cleaning is a high price to pay in order to save a renewable resource and some janitorial costs.
Nail brushes can double the effectiveness of handwashing. Used at the start of a shift, a nail brush provides a solid cleanliness baseline for the day. Because of the prevalence of norovirus in restrooms and its low infectious dose, a policy to require nail brushing after use of the restroom is in order. The best practice solution is to choose a fused bristle product. Staple-free bristles eliminate a potential harbor for germ growth and make these brushes recyclable in a dish machine, a power soak system, or a microwave.
Single-use gloves are another key to improved hand hygiene. Here too, the criterion for success is not price. Original quality, fit, appropriateness for task, and durability are the keys.
BACK-OF-HOUSE learning materials should emphasize the visual and use self-correcting methodologies. Language-free videos and the use of a “buddy” system can help all materials apply to both English and non-English speakers. “Visualize and personalize!” is our mantra for effective training that endures.
Motivation and Training
Weight loss provides a useful metaphor for the operator looking to change handwashing behaviors. Dieters have demonstrated that their food choices are not knowledge driven. They know the difference between a celery stick and a French fry, but lapses in self-discipline cause them to favor the fry. Dieting success is far more likely for a dieter wrapped in the discipline provided by a structured program in which weights are watched by a support group.
Process control in a restaurant depends on a foundation of employees’ self-knowledge, standards, and objectives.
Because standards have been set for both the quality and frequency of handwashing, we now have two numbers to work with as a base for improving the training and motivation of both worker and manager.
In covering frequency with the employee, the focus must be on connecting their behaviors, tasks, and situations with the risk of non-washing. Handwashing is not a function of time. The “per hour” time factor is applied strictly to normalize data for measuring progress.
Back-of-house learning materials should emphasize the visual and use self-correcting methodologies. Language-free videos and the use of a “buddy” system can help all materials apply to both English and non-English speakers. “Visualize and personalize!” is our mantra for effective training that endures.
Food workers must understand the risks associated with contaminated hands, hands that more than likely look clean. It is critical for staff to connect their good behaviors with personal, family, and customer wellness.
Starting with a breakdown of “at-risk” groups for the average away-from-home diner, a site-specific estimate is filled out by the staff. Knowing that a likely 20% of their customers have suppressed immune systems connects faces with the risk.
Foodborne outbreaks often close restaurants and eliminate jobs. Negligence can even result in individual lawsuits. This risk underscores the need for a personal standard for both quality and frequency.
No one wants to sicken customers, and the entire food handling team must accept their accountability. On the completion of training covering the why, when, how, and where of handwashing, the team members recite the Pledge of Professionalism aloud in their native languages:
I will wash my hands frequently to protect myself, my family, and our guests from foodborne illness. I will help my teammates do the same by my good example. (Additional languages are available at handwashingforlife.com.)
All food handlers sign this document for display in the kitchen. Names are added as new employees are hired and trained.
Every week, at least one employee is asked to retake his or her ProGrade demonstration of proficiency. This active reminder helps maintain enhanced behaviors as an ongoing operational standard.
Every six months, a team rally helps to maintain the priority of hand hygiene by adding excitement to a refresher event. Teams of three or four compete using the ProGrade scorecards. The fun starts as the event is announced and teams are formed. The process of naming the team adds to the enthusiasm. Prizes can be added to fit the situation.
Posters can be helpful reminders but have a short life span that can be extended by rotating them every two weeks before they disappear in the shadows of routine.
Commitment vs. Compliance
The pieces are in place. The pilot is complete. Facilities have been optimized where practical. The operations team now takes over ownership of the enhanced hand hygiene system and commits to its successful implementation. The temporary team is dissolved but is included in monthly reporting. It may be re-engaged after the first year to assess risk reduction and suggest any modification of standards.
Sustainability of any gains will only be achieved through leadership and a continuous program of setting and monitoring standards. Hand hygiene reports must be included periodically, along with profit reports to assure understanding that financial success can only be sustained in concert with food safety.
Handwashing reports are the scorecards of management’s commitment and ability to control the handwashing process. Compliance expectations are often based on that of the manager’s record in controlling food temperatures within safe limits.
Careful attention must be given in setting up feedback systems to fuel rewards for successful units—those regularly meeting the agreed standards for what Handwashing For Life calls ServeReady Hands.
The first available report is the log of Day One trainees backed by individual proficiency scores. Second is a weekly report on frequency in the form of a graph showing the trend of recent weeks.
Process control of handwashing will always have limits, often in the quality of its on-site managers and in facility compromises. The risk will never be zero. Liability insurance is a critical component to protect against failures in hand hygiene process control, as is the availability of an outbreak readiness plan. Prompt action during an outbreak saves lives—including, perhaps, the life of the business.
Jim Mann is the founder of Handwashing For Life and the Handwashing Leadership Forum, an alliance of best practice technologies for Overcoming Underwashing™ across the spectrum of away-from-home food preparation and service locations. Further information on implementation of a HandsOn System is available at www.handwashingforlife.com.