When dangerous bacteria or other contaminants get into the food supply—even if no one is harmed—businesses and government agencies have an opportunity to study what went wrong and to seek ways to avoid similar risks in the future. The investigative method known as root cause analysis can help public officials and companies determine how contamination occurred and why the food safety systems in place did not prevent it.
Although the tasks of identifying and recalling unsafe products take precedence, answering these deeper questions is crucial to better protecting consumers. That’s why experts taking part in the National Food Policy Conference in March and researchers writing in the journal Food Protection Trends call for new efforts to encourage these root cause analyses and stress the need to disseminate their lessons to businesses and regulators. Right now, these in-depth analyses are not performed routinely.
When shared widely, results of root cause analyses can prompt food safety advances at businesses that make comparable products, reducing risk and benefiting more consumers. At the conference, Jenny Scott, a senior adviser with the Food and Drug Administration, said findings from these investigations help the FDA develop guidance documents that companies can use to improve preventive measures in their supply chains. The agency has published reports from its own root cause analyses of major foodborne illness outbreaks, though Scott said it has conducted these studies only occasionally because of limited resources.
Successful root cause analyses benefit from cooperative relationships between public health officials and companies, according to Steve Mandernach, bureau chief for food and consumer safety with the Iowa Department of Inspections and Appeals and a conference panelist. For example, his office changed inspectors’ training and protocols to help build rapport with businesses implicated in outbreaks of foodborne illness. Investigators now focus first on working with a company to identify and fix flaws in its food safety system instead of citing the firm for regulatory violations—the traditional role of bureau staff. Mandernach said the emphasis on problem-solving promotes the frank and collaborative discussions central to productive root cause analyses.
Individual businesses and private groups, such as trade associations, also should promote the use of root cause analyses and the important benefits of sharing lessons learned. But the process can still face obstacles, such as tensions between a company’s investigators and its staff or with the suppliers whom they interview.
Panelist Steven Hermansky, chief food safety and quality officer for Conagra Brands, said that if employees perceive an inquiry as an effort to assign blame, they may be less willing to provide information needed to determine the underlying causes of a food safety issue. His team tries to promote worker comfort and candor by analyzing incidents of different levels of severity, close calls, and operational matters beyond food safety. He said this approach demonstrates that the practice is a routine part of the company’s culture and system improvement process, not a punitive exercise.
Companies often face additional challenges after completing root cause analyses. Concerns about legal liability and confidentiality may deter a business or trade group from sharing results with competitors and government regulators, or a company’s leaders may deem it too costly to devote staff time and other resources to distribution of the findings.
Sanjay Gummalla, vice president of scientific and regulatory affairs with the American Frozen Food Institute, said his group is committed to collecting and disseminating lessons from root cause analyses. However, he and other panelists underscored the difficulties in creating a regulatory environment and public policies that ease a range of concerns across the thousands of businesses supplying the nation’s food.
The authors of the article in Food Protection Trends—including two from The Pew Charitable Trusts—recommend that firms willing to share findings from their investigations capitalize on industry conferences and publications, such as academic and public health journals. They wrote that such opportunities have been missed in the past. For example, root cause analyses received scant attention in presentations at the International Association for Food Protection (IAFP) 2017 annual meeting. That gathering drew about 3,600 attendees from nearly 60 countries.
The researchers said organizers of IAFP meetings should dedicate more sessions to root cause analyses and generally encourage speakers to share lessons from these experiences. The same topics deserve greater attention at regional conferences so that new knowledge reaches businesses unable to attend national or international events. The authors also recommended that investigators in government and the private sector publish their findings in journal articles and the Centers for Disease Control and Prevention’s Morbidity and Mortality Weekly Report, a free resource widely read by food safety and public health professionals.
By seizing these opportunities to share the underlying causes of food safety lapses, companies can help their peers and public health agencies identify and address systemic weaknesses that expose consumers to preventable harm. Root cause analyses are crucial to understanding prior failures, but to maximize their benefits, their lessons must ultimately reach other enterprises at risk of making similar errors.
Sandra Eskin directs The Pew Charitable Trusts’ work on food safety, and Karin Hoelzer, a veterinarian, works on Pew’s safe food and antibiotic resistance projects.
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