Overcoming Underwashing. Driving. Implementation. Behavior. Change. to Lower. the Risk of. Foodborne. Outbreaks. [HOn/shortFormPG1-03/09]

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1 Overcoming Underwashing Driving Behavior Change to Lower the Risk of Foodborne Outbreaks [HOn/shortFormPG1-03/09] Implementation

2 Integrated Hand Hygiene The Hands-On is a 5 step risk-reduction process based on HAACP. Hands-On reduces the risk of outbreaks by providing simple site-specific solutions for clean hands, including the surfaces to keep clean hands clean. ServeReady Hands TouchReady Surfaces V Monitor I Assess Risk IV Train & Motivate II Set Safe Level Standards III Optimize ServeReady Hands TouchReady Surfaces Process, Equipment, Supplies TouchReady Surface Dirty Dozen Kitchen Service Area Restrooms Personal Touch TableReady ServeReady Hand Core Handwash ProGrade & Safe Level Quality Team Tally & Safe Level Frequency Team Rally SaniTwice [HOn/shortFormPG2-03/09] Flamingo Parkway, Libertyville, IL fax:

3 ServeReady Hands ServeReady Hands is the objective of this system. It starts with a risk assessment of current practices and sets a course to reach and sustain safe level standards. This Short Form Implementation Manual can be utilized by smaller operations to get started and often is all that is needed. For more complex organizations it is used to gather multi-department support, set up a trial and tailor the program to the individual operational culture. Hands-On s ServeReady Short Form component has been used successfully to conduct research regarding current policies and procedures and to raise standards of compliance. Risk Assessment/Team Formation Core Handwash ProGrade & Safe Level Quality Team Tally & Safe Level Frequency Team Rally SaniTwice H A N D S [HOn/shortFormPG3-03/09]

4 ServeReady Hands Risk Assessment/Team Formation Outbreak: Risk Overview of Impact (ROI) Location: Date: / / Our Risk Assessment Team: (not more than seven members) CEO / President CFO / Finance Manager Risk Management Food Safety, QA Consultant / Food Safety Auditor Facility Design & Construction Operations Human Resources Education / Training Other: Our Language of Risk Management includes: Annual Sales: $ Future Sales: 2 years $ 5 years $ 10 years $ Impact: Lost Opportunity: Out-of-Pocket Expenses Per Incident, Per Person: $ Emergency Room Visits, Hospital Days, Life-long Ailments, Deaths Other: Impact of Major Outbreak: Glancing Blow Same Year Recovery Crippling Significant Brand Devaluation Out-of-Business: Local - Yes / No Total Company - Yes / No Key Trends Affecting Our Risk: Consolidations Increasing Brand Values Improving Medical Assessment in ER and Consumer Awareness Improving Trace-back (CDC Network, Technology / DNA) Weaker Customer and Strengthening Pathogens Liability Other: Our Continuous Improvement Goal Over the Next Year: Risk Summary: Proposed Actions: 1) 2) 3) 4) 5) Approximation Curve Attached , HandwashingForLife [03/09] [HOn/shortFormPG4-03/09]

ServeReady Hands Setting The Safe Level Place an [x] where you are today An [o] where you ll be tomorrow! 1. Determine current handwashing by employees per hour.

Track and report. 4. Celebrate Success! Very High Risk High Risk Moderate Risk Low Risk Very Low Risk F O O D B O R N E I L L N E S S R I S K www.handwashingforlife.

5 ServeReady Hands Setting The Safe Level Place an [x] where you are today An [o] where you ll be tomorrow! 1. Determine current handwashing by employees per hour. Place an [x] Frequency Standard Selector Setting The Handwashing Frequency Standard 2. Set operational standard based on management guidelines of safe handwashing level. Pace an [o] 3. Track and report. 4. Celebrate Success! Very High Risk High Risk Moderate Risk Low Risk Very Low Risk F O O D B O R N E I L L N E S S R I S K E M P L O Y E E H A N D W A S H E S P E R H O U R Our Handwashing Frequency Standard Handwashes per employee per hour Handwashes per customer served US: UK: South Africa: copyright, HandwashingForLife [03/09] [HOn/shortFormPG5-03/09]

6 ServeReady Hands The Core Handwash 1. Wet/pre-rinse hands with warm water for 2 to 3 seconds. 2. Apply liquid or foam soap to hands. 3. Lather vigorously for 15 seconds, more when heavily soiled: Palm to palm Palm on backs of hands Claw paws in palms Between fingers Scrub wrists and forearms as appropriate 4. Rinse thoroughly. 5. Towel dry thoroughly with disposable paper towel. The Core + Handwash Add the use of a recyclable soft fused bristle nailbrush in step #3 for faster, deeper cleaning, especially around the nail beds and calluses. H A N D S [HOn/shortFormPG6-03/09]

7 ServeReady Hands ProGrade & Safe Level Quality Set a standard for handwashing proficiency, using a UV tracer lotion, Glitterbug (Brevis Corporation). Visually reinforce nail length and jewelry policies. ServeReady Hands 1 Spots- nails 2 Spots- other 1 (5) Areas- unwashed 8 Total Deductions 92 Nailbrush Used: Yes No Male Female is the Proficiency Grading component of the Hands-On. From a 100 point scale; 1 point is deducted for each unwashed spot and 5 points deducted for each unwashed area. Passing score is 90 points, or as established by your manager. Yes I did! Take the Hand Hygiene Pledge of Professionalism Name: Employee #: Company: Date: , HandwashingForLife [03/09] [HOn/shortFormPG7-03/09]

8 Facial / Grooming /Sneeze / Cough ServeReady Hands Team Tally Team Tally is a flexible combination of tools to help establish a meaningful standard for handwashing frequency for the team. There are some tasks in foodservice that trigger a handwash for everyone, like Upon Arrival and Restroom Use. Others vary depending on the role and the number of task changes. The best way to start is a series of Safe Level assessments with managers and the addition of a counter to the soap dispensers in the kitchen. Stage 1: Team Tally Safe Level Assessment Hands-On Safe Level Assessment Handwashing Frequency Worksheet copyright, Handwashingforlife Date: / / Arrival Pre / Post Break Restroom Use Task Change Pre / Post Gloving Customer Contact Other Departure Total Handwashes (per Shift) Notes & Comments: [HOn/shortFormPG8-03/09]

9 ServeReady Hands Team Rally Team Rally is a motivation, education and training event for the foodworkers and their managers. The Team Tally Safe Level assessment is repeated with all and the senior manager announces the Safe Level and the current level of Team handwashing. A chart is posted and program continues through the signing of the Pledge of Professionalism and the awarding of any certificates and awards as appropriate. New compliance charts are posted weekly as employee feedback in helping them maintain their Safe Level goal. P L E D G E O F C A R I N G I will wash my hands frequently to protect myself, my family, my teachers and classmates from illness. I will help fellow classmates do the same by my good example. Certified 1 SET UP SPACE & EQUIPMENT AGREE GOALS Training area to be located close to handsink and electric outlets. Kitchen is preferred for handwashing skill work. 2 OPENING DISCUSSION Discuss hygiene facts, misconceptions, cross-contamination, fecal-hand-oral route and susceptible customers. Scoring system explained, pass out ProGrade. Training ProgramGraduate 3 VIDEO SCREENING WHY, WHEN & HOW Discuss after each segment. What happened? What did you learn? What concerned you the most? What would you do differently? 4 QUIZ Work as a team to complete three quizzes. Introduce Step 5. Conduct Hand Condition Assessment. Use Safe Level handout to guide handwashing frequency. 5 HANDWASHING SKILLS TRAINING GlitterBug application Example of Splash & Dash Timed handwashes 6 HANDWASHING SKILLS ASSESSMENT Use ProGrade handout to score each handwash & discuss missed areas. (Nailbrush, sanitizer, glove options) Graduate(?) Date Something Something Else Team Rally Training Guide ACTION TIME PROPS Monitor/TV, check sound DVD player Tables/chairs 5 minutes Table Tents (for team names) Markers Top Ten hygiene facts ProGrade Scorecards Option: Shoe polish, toilet paper 15 minutes Handwashing For Life DVD The Why, The When & The How 10 minutes Handwashing For Life Quizzes The Why, The When & The How Pencils, stapler Skin Condition/ProGrade page w/safe Level Freq. on reverse. 10 minutes CSI UV Light & timer GlitterBug, sink/faucet, soap, recyclable nailbrush, paper towels (Sanitizer/glove options) Calculator 10 minutes (Individual and team scores are calculated as they are completed.) 7 PLEDGE OF PROFESSIONALISM Read aloud together. Each team member signs Pledge. 5 minutes Pledge of Professionalism poster, 8 CERTIFICATES AND AWARDS Award all team members with a certificate. Award medals to winning team. Take photo. signature pen Pledge holder (to post above handwash sink, preferably in view of customers) [HOn/shortFormPG9-03/09] Revised, Sept. 19, 2006 Handwashing For Life minutes Training Program Certificates Handwashing For Life Medals Digital camera

10 ServeReady Hand The convenience of SaniTwice translates to frequent use and lower risk. Locate your SaniTwice set-up in the middle of the action, in full view of the people you serve, visually confirming your care for them. SaniTwice SaniTwice helps operators pursue high standards of hand hygiene where food and beverages are served in remote locations where water is not readily available. On location training reminders are available for lamination and positioning directly on the Tork Tabletop Paper Towel Dispenser. A staff training quiz and certification form are available at handwashingforlife. com/sanitwice_hand_ washing_without_ water Best Practice Endorsements: The Handwashingforlife Institute actively supports and recommends the products and services of members who meet the criteria for leadership in hand hygiene related interventions. These criteria include: + Product or service must meet Institute standard of Best Practice within applicable category. + Forum member must demonstrate commitment to advancing the Science of Hand Hygiene and be a top quartile supplier, as measured by: Customer satisfaction with initial product or service and follow-up support. [HOn/shortFormPG10-03/09]

ServeReady Hand The SaniTwice provides foodservice workers with a simple hand cleansing method and managers with an integrated training protocol for service situations where soap and water are not

11 ServeReady Hand The SaniTwice provides foodservice workers with a simple hand cleansing method and managers with an integrated training protocol for service situations where soap and water are not readily available and where hand soiling is light to moderate. Catering functions including buffet lines, portable bars and off-site events are examples where the SaniTwice method can be used effectively, provided there is no handling of raw meats, fish or poultry. [HOn/shortFormPG11-03/09] The Science of SaniTwice The SaniTwice principle is simple. Food Code compliant sanitizers containing appropriate levels of alcohol (65%+) will loosen, suspend and dissolve light soil, dirt and grease on the skin. Vigorous drying of your hands with a good paper towel before the gel/alcohol evaporates, will absorb and remove both the soil and many of the microbes. The application of sanitizer a second time, allowing it to air dry on your hands without wiping, kills remaining bacteria and virus. SaniTwice is the scientific equivalent of a handwash for light to moderately soiled hands. The method will work effectively with food safe gel type hand sanitizer where the alcohol level is 65%+. Some commercial formulations are available with boosted performance on norovirus. Single-use paper towels are an integral component of SaniTwice. A paper towel with high absorbency and good wet strength is recommended to effectively remove the suspended dirt, grease and germs. A hands-free dispenser for the paper towels is essential to prevent cross-contamination from levers. Electronic dispensing is preferred. How to use SaniTwice 1. Apply a generous amount of Food Code compliant sanitizer (double the normal recommended dosage). 2. Scrub your hands for 20 seconds as if washing with soap and water. Insure sanitizer reaches between fingers, around/under fingertips, and your wrists. 3. While hands are still wet, use a clean paper towel and vigorously dry them. Discard used towels in wastebasket. 4. After drying, apply a normal dose of sanitizer and let it air dry. 5. Don NSF certified gloves where applicable. When to use SaniTwice When handwashing is necessary due to light or moderate soiling, but soap and water handwash facility is not available. Before and after setting up your work station. Just before serving your first guest. Before cutting fruit, handling garnishes or serving Ready-To-Eat food. After using your cloth chefs towel for any reason. Before and after using disposable gloves. Whenever your hands are lightly soiled, sweaty or may be contaminated. Set up: Check dispensers for supply quantities and functionality. Service as required. Place the sanitizer and towel dispensers together in a safe and stable location. Place dispensers conveniently close to the worker. Position wastebasket accordingly. Important! SaniTwice IS NOT an alternative to handwashing at the beginning of the shift or after visiting the restroom. If there is a choice between SaniTwice and using soap and water to wash hands, use soap and water. Always use soap and water when heavy soil loads are involved. When handling ice, food, garnishes, condiments etc, AVOID DIRECT BARE-HAND CONTACT by using scoops, tongs, picks or clean single-use gloves.

12 TouchReady Surfaces TouchReady is the application of the Hands-On to surface cleanliness as well as a summary of the outcome. TouchReady cuts the risk of outbreaks by providing an integrated process to maintain cleanliness standards for those surfaces most likely to contaminate hands. ATP (Adenosine triphosphate) is the technology of choice to define success. This system aligns standards with the owner s values, level of process control and tolerance for risk. Surface Risk Assessment* Dirty Dozen- Kitchen Service Area Restrooms Personal Touch TableReady* SURFACES [HOn/shortFormPG12-03/09] * Under Development

TouchReady Surfaces Dirty Dozen Dirty Dozen is a survey of the facility s most likely harbors of bacteria and virus that could lead to an outbreak.

From these 36, 12 are selected for the first round of examination where surface cleanliness standards are set, cleaning protocols and frequencies are established and implemented.

13 TouchReady Surfaces Dirty Dozen Dirty Dozen is a survey of the facility s most likely harbors of bacteria and virus that could lead to an outbreak. It systematically guides the manager and the food safety team through three separate zones - the kitchen, service area and restrooms - selecting the 12 highest risk surface-to-hand contact points. From these 36, 12 are selected for the first round of examination where surface cleanliness standards are set, cleaning protocols and frequencies are established and implemented. Reporting forms are developed as well as the flow of performance data, with the results reaching from Quality Assurance to Operations, Risk Management and back to the staff responsible for the cleaning. Dirty Dozen* [HOn/shortFormPG13-03/09] This HACCP based survey seeks to identify high-touch surfaces that could contaminate food worker hands. ATP is the monitoring technology used to determine the twelve most likely surfaces that harbor pathogens and cause an outbreak by cross-contamination. This assessment helps raise surface cleanliness standards. TouchReady surfaces keep clean hands clean and lower the risk of foodborne outbreaks. My Top Five Picks: (Place a 1 in the box aligned with your top choice, continuing through 5 completing your Top Five Picks.) Male Female Comments: (optional) Kitchen: 1. Cutting board 2. Refrigerator door handle 3. Ice bin 4. Handsink faucet handle 5. Paper towel lever Restrooms: 6. Restroom stall door lock 7. Restroom flush handles 8. Soap levers/button 9. Paper towel l/hot air levers/button 10. Restroom exit door handle Customer Service Area: 11. Service counter 12. Customer tabletop See TouchReady & TableReady to further assist in setting surface cleanliness specifi * Dirty Dozen surfaces are site-specific choices based on ri Check website for more information o Fax: overcoming underwashing Norovirus Salmonella

14 TouchReady Surfaces Dirty Dozen - Kitchen [HOn/shortFormPG14-03/09] Notes: Kitchen s Dirty Dozen* Many kitchen surfaces are touched frequently and cleaned infrequently. Contaminated surfaces, particularly those which are touched with force, contaminate the hands. Handles of refrigerators, faucets and ice machines are prime examples. (See attached kitchen equipment listing.) Use the accompanying listing of kitchen surfaces to facilitate your review and observational assessment. After choosing your top 12, please rank the priority of importance by placing a 1 in the box aligned with your top choice, continuing through 12. * Dirty Dozen surfaces are site-specific choices based on risk. Check website for more information on TouchReady surfaces. Norovirus Salmonella See TouchReady & TableReady to further assist in setting surface cleanliness specifications. Fax: underwashing Kitchen s Dirty Dozen* * Dirty Dozen surfaces are site-specific choices based on risk. Things You Touch- Door Handles: Employee entrance Employee exit Customer entrance customer exit Men's room door entrance Men's room door exit Women's room door entrance Women's room door exit Equipment Handles: Reach-in Refrigerator 1 Reach-in Refrigerator 2 Reach-in Refrigerator 3 Walk-In Cooler Walk-In Freezer Reach-in Freezer Oven 1 Oven 2 Oven 3 Drawer 1 Drawer 2 Drawer 3 Utensil Drawer Oven dials Range dials Pot holders Faucet Handles/Sink Surfaces: Handsink 1 faucets Surface Soap dispenser pusher/puller Towel dispenser lever Handsink 2 Handsink 3 Handsink 4 Handsink 5 Prep sink - faucet handle Pot sink - faucet handle Pot filler - faucet handle Dishwashing pre-spray trigger Drain board of pot sink - soiled side Drain board of pot sink - clean side Floors: Drain area Floor surface 1 Floor surface 2 Work Surfaces Prep Line: Cutting Board Cutting Table Knife - boning Knife Knife Knife Cooking oil container/ladle (on hot line) Salt container (on line) Portion scale Probe thermometer DIAL (not the sanitized probe!) Tables, dishes, flatware, glass storage: Prep table 1 Prep table 2 Dish drain board - clean side Plating, Pick-up Surfaces (RTE Stage): Pick-up counter/window Surface 2 Surface 3 Order printer Ice Machine door handle Inside ice machine, upper seam Ice Bin Ice scoop Drop-off, Cleaning Tools, Gloves: Bus/service station drop-off Cleaning/Sanitzer bucket Sanitizer dispenser trigger Wipe rag Mop handle Non-disposable gloves (dishwashing, cut-guard safety, etc) Disposable gloves mis-used (not changed, etc) Water/Sanitizer Solutions copyright HandwashingForLife [DdozKtchn-03/09] See TouchReady & TableReady to further assist in setting surface cleanliness specifications. Fax: overcoming underwashing copyright HandwashingForLife [D

15 TouchReady Surfaces Dirty Dozen - Service Area Service Area s Dirty Dozen* Norovirus cruises comfortably around busy restaurants, the busier the better. ATP (Adenosine triphosphate) technology can now help set surface cleaning cycles and maintain safe standards without the delays of lab culturing. Swabs and a hand-held luminomteter provide surface cleanliness readings in 25 seconds. Please rank the priority of importance by placing a 1 in the box aligned with your top choice, continuing through 12. Entry Door Reception/Waiting Area Table Menus Condiments (Salt, Pepper, Sauces, Sweeteners) Tray Return/Trash Beverage Station Salad Self-Service Breading Station Ill Customer Contact with Server Cashier Exit Door Notes: underwashing Norovirus Salmonella See TouchReady & TableReady to further assist in setting surface cleanliness specifications. * Dirty Dozen surfaces are site-specific choices based on risk. Check website for more information on TouchReady surfaces. Fax: copyright HandwashingForLife [DdozSrv-03/09] [HOn/shortFormPG15-03/09]

16 TouchReady Surfaces Dirty Dozen - Restroom Restroom s Dirty Dozen* Restrooms are the dominant source for norovirus, the leading cause of restaurant outbreaks. This highly virulent pathogen commonly escapes from toilets via invisibly soiled hands. Norovirus can live on restroom surfaces for 3-6 weeks, waiting to be picked up and transfered to ready-to-eat foods. Please rank the priority of importance by placing a 1 in the box aligned with your top choice, continuing through 12. Toilet paper Poke-Thru (Direct contamination) Toilet seat/bowl contact Splash-back (Aerosolizing during flush) Flush handles Stall door Floor/shoe/purse contact Faucet handles Soap dispenser Paper towel dispenser (Lever/crank) Accessories/toiletries Countertops Restroom exit door Notes: underwashing Norovirus Salmonella See TouchReady & TableReady to further assist in setting surface cleanliness specifications. * Dirty Dozen surfaces are site-specific choices based on risk. Check website for more information on TouchReady surfaces. Fax: copyright HandwashingForLife [DdozRrm-03/09] [HOn/shortFormPG16-03/09]

17 TouchReady Surfaces Personal Touch Personal Touch is an extension of the Dirty Dozen survey, adding the probability of transfer factor. Personal Touch is a combined risk assessment, implementation and employee training tool. It is a simple chart that helps prioritize those touches that should trigger a handwash. It provides a picture of the relationship between two critical variables. The vertical axis (Y) rises from the clean to the heavily contaminated surface while the horizontal axis (X) increases in transfer probability from left to right. The sample template is provided with four high priority touches plotted on the coordinates to get started. The High-High corner is clearly for the must wash events. Personal Touch Program x Prioritizing the touches that trigger handwashing. Surface Risk Hand Transfer Probability Where the Pathogens Score: Red Zone High Risk Surface / High Transfer Probability / Return from restroom, work on salad prep Orange Zone Yellow Zone Green Zone Receive delivery, sign receipt [HH/shortFormPG16-03/09]

TouchReady Surfaces Table Ready Under Development TableReady narrows the focus of TouchReady to a cleaning sub-system specifically targeting the dining area.

18 TouchReady Surfaces Table Ready Under Development TableReady narrows the focus of TouchReady to a cleaning sub-system specifically targeting the dining area. It too is a risk-based process to set safe level standards and package training with implementation and monitoring. The core of TableReady is the marriage of cleaners with single-use paper towels - replacing the traditional multi-use rag, maintained in a bucket of poorly controlled sanitizer solution. Dr. Charles P.Gerba, University of Arizona, demonstrated that in some cases the multi-use rag method just moves germs from one spot to another while giving staff and patrons an impression of cleanliness. Adding cleanliness standards can change this picture and help operators move to the TableReady method where a spray bottle of fresh sanitizer solution is used in conjunction with a single-use paper towel. TableReady uses ATP technology to develop a site-specific package: Risk assessment summary Safe Level standards & task frequency Sanitizer Paper towel & dispenser/s Training Verification & auditing schedule Report flow, worker feedback [HOn/shortFormPG17-03/09]

Risk Assessment Workshop

Risk Assessment Workshop AN INTERNAL MULTI-DEPARTMENT COLLABORATION 1 The 5 Handwashing Hurdles WINNING WITH THE HANDSON SYSTEM Corporate Complacency our no-problem history Operation s Priorities productivity