Public Health – Seattle & King County (Public Health) is one of the largest metropolitan health departments in the United States (U.S.). Serving a resident population of 2.1 million people1 speaking over 100 languages, Public Health’s mission is to protect and improve the health and wellbeing of all people in King County.2 Between 2000 and 2016 the county’s population grew by 21%, with most of this growth coming from immigrants from all parts of Asia, Latin America, Eastern Europe, and Africa.3
Each year, millions of Americans get sick, hundreds of thousands are hospitalized, and thousands die as a result of foodborne diseases.4 To help with this issue, local governments support access to healthy food by ensuring adequate systems are in place to monitor the safety of the food within their jurisdictions. This is primarily done through the inspection of retail food establishments by local, county, or state public health departments. Increasingly, municipalities are also passing restaurant-grading ordinances that include the requirement that retail food establishments post food safety rating or sanitation grading information in a highly visible place, such as in restaurant windows.
These schemes are meant to provide consumers with simplified food safety information at the time of decision-making or purchase, and many large U.S. cities, including New York and Los Angeles, are already using restaurant grading systems. While these ordinances are gaining in popularity, researchers have called into question the efficacy of restaurant food safety grading in decreasing outbreaks of foodborne illness.5 6 7 8
|Population: 1||2.1 million|
|Land Area (in sq. mi):||2,307|
6.2%-Black or African American
8.9%-Hispanic/Latino (of any race)
|Population by Age: 2||20.7%-under 18 years
10.9%- 65 years and older
|Education: 3||92.7%-High school graduate or higher
50.3%-Bachelor’s degree or higher
|Median Household Income: 3||$83.571|
|Population in Poverty: 3||10.2% (compared to 12.2% statewide and 14.6% in the U.S. as a whole)|
In addition, the equity impacts of restaurant grading on smaller food establishments, especially those serving culturally diverse populations, can be cause for concern.9 King County’s Equity and Social Justice (ESJ) Initiative, launched in 2008 and codified in 2010, calls on local government to use an equity lens in policy and decision making, organizational practices, and engagement with the community. To create a more prosperous and inclusive region for all, ESJ created an opportunity for Public Health to understand how those "who have been most disenfranchised—low-income residents, communities of color, and immigrants and refugees—could be prioritized in decisions and practices."10
Since 2001, detailed, publicly accessible restaurant inspection reports have been available online through Public Health’s Food Protection Program. But, in 2014, after a series of outbreaks of foodborne illness within the county and growing consumer demand for easier access to food safety information11, the King County Board of Health tasked Public Health with implementing a restaurant sanitation grading system. The King County Board of Health operates as a committee of the larger municipal council. Comprised of elected officials, the Board of Health oversees the county’s department of Public Health, which is charged with day-to-day policy implementation and administering the county’s programs.
To design the King County food safety rating system, Public Health embarked on a multi-year journey with a variety of internal and external stakeholders to analyze restaurant inspection reports, work with food safety inspectors, and hear and respond to concerns from community members and restaurant owners.
One of the key barriers in implementing an equitable food safety rating system was the concern among King County restaurant operators, especially owners of small, minority-owned restaurants, about a lack of consistency among the county’s food safety inspectors. Knowing this was an underlying issue, in 2014 Public Health staff reached out to Dr. Daniel Ho, Stanford Law School professor and leading scholar in regulatory enforcement. This started an academic and public health agency partnership in collaboration with Stanford’s Regulation, Evaluation, and Governance Lab that continues today.
Dr. Ho used his research on food safety rating systems in other locales to help King County develop and test a peer-review program that would ultimately determine how to improve consistency and reliability among food inspector ratings. Working together, the team designed a randomized control trial where they enrolled half of the food safety inspection staff in a four-month program. For one day out of the week, these staff were randomly paired and assigned to a set of establishments. The two-person teams visited food establishments within Public Health’s jurisdiction, observed conditions, independently cited health code violations, and then came together to talk about where they diverged and why.
Using the findings from the trial, the team developed a series of training programs, remaining committed to the inclusive dimensions of the ESJ initiative. Supervisors, plan reviewers, and frontline inspectors were all randomized into the peer review training program in an attempt to institute a culture of mutual learning and respect. Quantitative data showed that independent inspection scores went up as a result of the peer review training, but the most remarkable outcome was that inspection scores increased largely for inspectors who generally awarded low scores, therefore improving the reliability of the inspection system and its consistency overall.12 After this, King County worked to institute peer review for the staff as a whole, even before the food safety rating system ordinance was adopted.
Public Health also involved restaurant operators and the community in developing the food safety rating system. They held multiple stakeholder meetings, and they put special effort into engaging owners of smaller establishments, especially immigrant and refugee families, to solicit feedback from diverse perspectives. Public Health consistently heard from these meetings that a food safety rating should not be based on a single inspection and that people wanted to know more than just whether a restaurant passed or failed an inspection.
As the signage for the food safety rating placards was developed, Public Health continued to solicit community feedback. They heard from owners of Asian food establishments that the use of yellow for the lowest category, “needs to improve,” was concerning as owners felt the system was linking high food safety risk to skin color. This was an unexpected finding, but something that once identified was an easy fix for Public Health. Ultimately, the final signage design, in terms of color selections and facial expressions, as well as its simplicity, was informed by community input.
Another outcome of engaging the community in developing the food safety rating system was that it reinforced Public Health’s need to address consistency among inspectors as well as the power dynamics between public health inspectors and food establishment operators. It prompted Public Health to use an equity lens not only in the development of the food safety rating system, but also in considering how to redesign food safety educational opportunities and communications materials for communities with limited English proficiency or no internet access.
Ultimately, Public Health used data and community engagement to inform and develop a rating system that improved inspection quality and consistency, addressed equity concerns, and provided consumers with the food safety information they wanted. The ordinance that amended the county’s existing food safety permitting law was adopted in January 2017 and addressed the following: 1) the definition of the food safety rating placard; 2) the requirement for posting window signs; and 3) the incremental penalty scale for failure to properly post the placards.13
The final policy based a restaurant’s rating on the last four routine inspections and only critical violations. Using the peer review evidence and years of retail food inspection reports, Dr. Ho recommended that Public Health base the system on “red” critical violations only (e.g., lack of hand washing, bare hand contact with ready-to-eat foods), and not “blue” noncritical violations (e.g., how establishments put away and use utensils), since noncritical violations were cited much more inconsistently among Public Health staff. Data analysis also informed the decision to use the average of red critical violation points from a restaurant's last four routine inspections to determine the rating. In addition, Public Health added an adjustment for the area in which the inspection was conducted in order to create a food safety disclosure system that has meaningful variation for patrons within a particular area.
The four food safety ratings that restaurants may now receive are as follows:
This image demonstrates how community feedback on early drafts of the food safety rating system informed the final product by making it more inclusive:
In the new Food Safety Rating System, restaurants are required to post their rating placards in an easily visible place. Because every restaurant is different, Public Health inspectors work with restaurants to find the best place to post the window sign in accordance with the code of the King County Board of Health, which requires that a sign is clearly visible to people passing by or entering the establishment.
If the food safety rating placard is not properly posted as required by the law, a penalty fee can be charged. Penalty fees are a percentage of a business’ annual permit fee, which is more equitable than a flat fee because it is relative to the business size. The fee amount increases incrementally with each offense within a two-year period.
An in-depth evaluation of the impact of Public Health’s food safety rating system is expected to be released soon. Just as in the policy development stage, Public Health continues to rely on data and community engagement to inform the effectiveness of the implementation and identify equity impacts on businesses, especially small, family, and immigrant-owned establishments struggling to maintain profitable businesses. The evaluation findings will guide possible changes that may need to be made to improve the system and ensure equity.
The feedback on the new system from the state Department of Health and most retail food establishments has been positive. Anecdotally, food establishments with businesses in multiple cities throughout Washington State have asked other health departments to follow Public Health’s lead. Some food establishment operators have also shared that the rating system has increased motivation amongst their staff to follow food safety practices more consistently. Additionally, Public Health has found that posting food safety ratings has led to increased dialogue about food safety and provided an opportunity for community education. For example, the smiley-face signage is very child friendly, prompting families to talk about food safety practices as they dine out.
Public Health spearheaded the development and implementation of the food safety rating system, as local government, consumers, and the news media were all extremely engaged in the process. Although there have been a few hiccups in the roll out of the new policy, Public Health is undeterred in carrying out its mission to protect and improve the health of all people in Seattle and King County.
1 King County’s Changing Demographics. Presentation by Chandler Felt, Demographer King County Office of Performance, Strategy and Budget Updated in 2016 from June 2013 County Council Presentation. Available at: https://www.kingcounty.gov/depts/executive/performance-strategy-budget/regional-planning/Demographics.aspx
2 Public Health – Seattle & King County: About Us. Available at: https://www.kingcounty.gov/depts/health/about-us.aspx
3 King County’s Changing Demographics. Presentation by Chandler Felt, Demographer King County Office of Performance, Strategy and Budget Updated in 2016 from June 2013 County Council Presentation. Available at: https://www.kingcounty.gov/depts/executive/performance-strategy-budget/regional-planning/Demographics.aspx
4 CDC: Estimates of Food-Borne Illness in the United States. Available at: https://www.cdc.gov/foodborneburden/2011-foodborne-estimates.html
5 Boehnke, R.H., & Graham, C. (2000). International survey on public posting of restaurant inspection reports, and/or grade card posting schemes based upon health inspections. Region of Ottawa-Carleton Health Department Ed., Ottawa, Canada; Loewenstein G, Sunstein C, & Golman L. (2014). Disclosure: Psychology Changes Everything. The Annual Review of Economics. 6(1):391-419.
6 Wiant C.J. (1999). Scores, grades, and communicating about food safety. Journal of Environmental Health, 61(9), 37-39.
7 Ho D, Ashwood Z, & Handan-Nader C. (2019). New Evidence on Information Disclosure through Restaurant Hygiene Grading. American Economic Journal: Economic Policy (forthcoming).
8 Ho D. (2012) Fudging the Nudge: Information Disclosure and Restaurant Grading. Yale Law Journal. 122(3):574-688.
9 Ho D. (2017). Equity in Bureaucracy, Irvine Law Review 7: 401-52.
10 King County Equity and Social Justice Initiative. Available at: https://kingcounty.gov/elected/executive/equity-social-justice/strategic-plan/equity-strategic-plan.aspx
11 Food Safety News: Two-Time E. Coli Victim Pushes to Improve Seattle’s Restaurant Grading System. Available at: https://www.foodsafetynews.com/2013/08/two-time-e-coli-victim-pushes-to-improve-restaurant-grade-info/
12 Ho, D. (2017). Does Peer Review Work? An Experiment of Experimentalism, Stanford Law Review 69(1): 1-119.
13 Additional documents and videos related to the promulgation of the regulation can be found here: https://mkcclegisearch.kingcounty.gov/LegislationDetail.aspx?ID=2914885&GUID=6EED2D0F-3971-4F76-8859-BDAA041113BB&Options=&Search.