Public Health – Seattle & King County (PHSKC) is located within the Puget Sound region of Washington State and serves a population of over 2.23 million people across a land area of 2,307 square miles – nearly twice the size of the State of Rhode Island. In 2018, 58.7% of the population identified as White (non-Hispanic), 17.8% identified as Asian, 6.58% identified as Black or African American, and 5.61% identified as more than one race. King County is also home to many immigrant and refugee communities, with 21.8% of the population born outside of the United States.

Since the beginning of the pandemic, PHSKC’s Environmental Health Services Division was tasked with ensuring food establishments were compliant with Washington State Governor Jay Inslee’s COVID prevention requirements. Initially during the “Stay Home, Stay Healthy” order, food inspectors ensured businesses remained closed for indoor food service as part of their regular food safety inspections. When Governor Inslee implemented phased “Safe Start” reopening requirements for businesses and King County entered “Phase 2” allowing limited indoor service on June 19, 2020, PHSKC’s Environmental Health Division mobilized a Division-wide effort to provide technical assistance on the new requirements, and conduct progressive enforcement with non-compliant businesses.

The Safe Starts for Taverns and Restaurants (SSTAR) program began providing on-site technical assistance on July 3, 2020, while also using existing enforcement authority under the food code to prevent imminent health hazards. To clarify that authority, PHSKC Director Patty Hayes issued an Emergency Rule to declare non-compliance with the Governor’s Safe Start order an imminent health hazard.

The SSTAR program was organized using the principles of the National Incident Management System (NIMS) and Incident Command System (ICS) and build out capacity to address the following six core objectives:

·         -Support food establishments in the successful implementation of COVID-19 prevention measures.

·         -Engage with the hospitality industry, community-based organizations, and agency partners to increase technical assistance available to food establishments.

·         -Provide and assist businesses in obtaining financial support to implement COVID-prevention measures.

·         -Identify potential barriers and address public health equity concerns regarding compliance with the COVID-19 prevention measures.

·         -Highlight businesses successfully meeting or exceeding COVID-19 prevention measure to promote industry best practices.

·         -Conduct progressive compliance with businesses that failed to respond to technical assistance and remained out of compliance.

As of December 21, 2020, the SSTAR program has completed more than 2,075 site visits, reaching 1,845 different locations. While a vast majority of sites visited were observed to be mostly in compliance, the technical assistance provided by SSTAR staff helped bring almost all sites into satisfactory compliance with COVID-19 prevention measures. Operating permits were suspended at only two facilities for violations of COVID-19 prevention measures. In those cases, both establishments reopened promptly after developing an approved COVID prevention plan.

Taking on an equity approach from the beginning, the SSTAR program was able to also leverage available resources to provide direct material support and financial assistance to those most impacted by COVID-19.

PHSKC’s Environmental Health Services Division launched the SSTAR program in response to the newly established guidelines – issued by Washington State Governor Jay Inslee – to allow the resumption of indoor dining and reopening of food establishments following the statewide “stay-at-home” order issued in response to the initial wave of COVID-19 in late spring and early summer of 2020. Through the authorities of an emergency rule that was enacted by King County Public Health Director Patty Hayes, extending the scope of the county Board of Health Food Code to include provisions for the enforcement of the Governor’s guidelines. The SSTAR program was developed and tasked with ensuring food establishments were complying with the Governor’s safe start reopening requirements in order to help mitigate the spread and transmission of COVID-19.

With staff already reassigned to assist in other areas of the Department’s COVID-19 response, and only a limited number of staff remaining available to maintain continuity of operations for other essential environmental health services, PHSKC’s Environmental Health Services Division recognized its staffing resource limitations. However, using the principles of Incident Command System (ICS), Environmental Health Services Division leadership was able to pull staff from all programs across the Division to rapidly develop, organize, and operationalize an entirely new program in a matter of weeks. The program set out core objectives, and through a continuous improvement process, refined the program’s operations and staffing structures to constantly adapt to changes in guidelines and restrictions for food establishments, as they were released by the Governor’s Office.

Distilling the Governor’s safe start reopening guidelines for food establishments down to nine (9) general COVID-19 risk categories and associated prevention measures:

1.       Employee screening

2.       Employee face coverings

3.       Employee social distancing

4.       Proper sanitation procedures

5.       Collection of contact tracing information

6.       Correct seating capacity

7.       No provision of bar or counter services

8.       Customer facial coverings

9.       Customer social distancing

A set of “marking instructions” was developed for field staff to help standardize and record field observations. During on-site food establishment assessments, observations in each category were recorded as being in: a) full compliance; b) partial compliance; c) non-complaint; or, d) applicable – but not observed. Facilities identified as being non-complaint with any of the COVID-19 prevention measures were given 72-hours to make identified corrective actions to bring them into compliance, or risk suspension of their food operating permit accompanied by public disclosure of the closure. Operators identified as being in partial compliance with any of the prevention measures were provided with technical assistance and recommendations to bring them into full compliance – often resulting in corrections being made by operators during-the-course of the on-site assessment.

Since the launch of the SSTAR Program, staff have completed over 2,000 COVID-19 prevention site assessments, providing technical assistance to over 1,800 different bars, restaurants, and taverns operating across the county.

Education and community engagement are critical in helping food establishments and communities understand the COVID-19 prevention measures, including frequent changes released from the Governor’s Office. Therefore, from early in the program’s development a strong emphasis was placed on providing education and guidance to help encourage voluntary compliance.

Partnering with neighborhood associations, local chambers of commerce, hospitality associations, and community-based-organizations, the SSTAR program arranged and conducted informational webinars that included language access translations into key languages spoken by communities in King County, including Spanish, Amharic, Mandarin, Korean, Chinese, Cantonese, Vietnamese. COVID-19 prevention guidance materials for food establishment operators were also translated into multiple languages and distributed to operators during SSTAR site assessments and made accessible online through King County’s website.

In addition, to further the SSTAR program’s reach and ability to connect with all members of the community – including immigrant and refugee communities – the SSTAR program launched a dedicated ethnic media outreach campaign. Providing paid services for ethnic media outlets to help amplify community messaging around COVID-19 prevention measures and to help promote the availability of resources to help support struggling businesses most impacted by the restrictions on social gathering due to the COVID-19 pandemic.

With a second wave of widespread community transmission that began in the Fall, the magnitude of impact COVID-19 was having on food establishments became evident. Without additional assistance, many food establishments were at risk of losing their businesses, as they struggled to afford the additional costs to make necessary retrofits and changes to their businesses to allow them to comply with the Governor’. Observing with the burden of impact disproportionately affecting minority-owned small-businesses, the SSTAR program was able to obtain $500,000 in CARES Act Congressional Relief Funds to administer a financial assistance program. $400,000 was distributed directly to 143 small businesses to reimburse for costs associated with COVID-19 prevention measures, and $100,000 was used to purchase and distribute essential COVID-19 sanitation and prevention supplies through a mobile “SSTARship” outreach campaign that stationed technical assistance staff in neighborhoods with high densities of food establishments.

With federal funding ending on December 30, 2020, the SSTAR program will continue its support for food establishment operators to ensure safe operating conditions for staff and patrons that mitigate the potential for COVID-19 transmission until the pandemic is over.

From the beginning, equity has been a central value of the Safe Start for Taverns and Restaurants (SSTAR) Program.

At the beginning of the program, a draft of the Director’s Emergency Rule was reviewed with a racial equity lens to ensure implementation would not disproportionately impact communities of color and low income communities. The equity review identified the clear need for communication, community partnership, and education aimed at helping food establishment operators understand their role in helping to prevent the spread and transmission of COVID-19. The SSTAR Program was adapted accordingly to take on more of a community technical assistance role in its capacity than a stringent compliance enforcement approach. In addition, based upon the findings of the equity review, the SSTAR Program created a specific team responsible for community engagement and ethnic media, and created a dedicated Equity Officer role in the leadership structure of the program. Experienced equity staff in that role helped ensure equity considerations were taken into account in all programmatic operations and decision making processes on a continual basis. That includes but is not limited to creating a low-barrier financial assistance program focused on businesses with the highest needs (as described below).

Upon the formal launch of the SSTAR Program, the SSTAR Community Engagement Team had partnered with the local hospitality association and local neighborhood business associations to conduct series of informational webinars to disseminate guidance on how to comply with the COVID-19 Safe Start Reopening Requirements. During the first two informational sessions, the SSTAR program engaged with over 600 participants. And over the course of the first several weeks of the SSTAR program, the SSTAR Community Engagement Team held seven informational webinars in partnership with the County’s Small Business Task Force, with translation and interpretation services being provided in five different languages.

Through the combined efforts of the SSTAR Community Engagement Group and the SSTAR Equity Officer, the program was able to leverage relations with existing community-based organizations and neighborhood business associations that PHSKC had prior working relationships with. Increasing the reach of the SSTAR Program’s community engagement efforts to promote industry awareness of the Safe Start COVID-19 prevention requirements. Factsheets, guidance checklists, and frequently-asked-questions (FAQs) were also developed and translated into multiple languages including, Spanish, Chinese, Korean, Vietnamese, Russian, and Amharic, and provided to food establishment operators through outreach to neighborhood business associations, community-based organizations, and during the course of SSTAR food establishment site assessments.

While the SSTAR program’s site assessments evaluated compliance with the Governor’s Safe Start requirements, the assessments also worked to identify and address potential barriers operators might face with regards to complying with the Governor’s Safe Start requirements. With regulatory enforcement being reserved for the most egregious cases, and the primary goal of increasing compliance with the Governor’s Safe Start requirements, SSTAR environmental health investigators were able to work with food operators to provide technical assistance while out in the field during SSTAR site assessments. Often resulting in minor corrections being made by operators during the investigation to bring them into compliance with the COVID-19 prevention requirements. By using a more technical assistance-oriented approach, the SSTAR program was able to help build trust in communities and demonstrate to food establishments that the SSTAR program was there to help.

By early October, it was recognized that many food establishments were struggling and operating on razor thin margins as they tried to stay open and adjust to new operating requirements released by the Governor’s Office. Realizing the financial constraints food establishments were facing, the SSTAR program obtained $400,000 in CARES Act Funding to provide direct financial assistance to assist struggling businesses through reimbursement of costs incurred as a result of complying with the Safe Start requirements. Given that other CARES Act funded business assistance programs frequently benefitted English-speaking and more well-resources businesses, the SSTAR program was specifically focused on smaller business in areas that have been historically marginalized and under-resourced. The program identified low-income communities throughout the county and prioritized minority-owned small-businesses, using targeted solicitation for applicants in a language accessible manner for non-English speaking operators.

The SSTAR program’s Community Engagement Group was also able to secure an additional $100,000 in CARES Act funding for the direct procurement and distribution of basic sanitation and disinfection cleaning items. Through a mobile community outreach strategy coined the SSTAR Ship Mobile Outreach, staff were able to provide key resources in addition to guidance to food operators throughout the county.

The efforts of the SSTAR program highlight the need for cultural competency when dealing with enforcement, ensuring operators receive the appropriate guidance and support to be successful.

Throughout the response, the SSTAR strategy for communication and outreach, financial assistance, and site assessment were adapted to the needs of the community based on the evolving landscape of COVID-19.

A field deployment strategy was developed to focus outreach in areas of the County with the highest incidence of COVID, high concentrations of food establishments, and businesses experiencing suspected or confirmed workplace outbreaks. Deployment strategies were adapted with changes in the governor’s orders and reopening requirements, including focusing on outdoor venues following new indoor dining restrictions implemented in November 2020.

At the beginning of the SSTAR program, the deployment strategy was focused on visiting a wide range of zip codes throughout King county, so that as many establishments  as possible could be provided with technical assistance. As the outbreak continued, the focus shifted to zip codes where new cases of COVID-19were highest. Aiming to protect those in areas where COVID-19 was most prevalent and focus on providing guidance on food worker health, as more data came in about how hard it was for employees in small kitchens to practice safe COVID-19 behaviors. As more data became available on the risk factors of COVID-19 among clientele and restaurant patrons and processes were established to receive and respond to complaints, the deployment strategy shifted to focusing on visiting establishments that also served alcohol and  those receiving multiple public complaints. As winter approached, food establishments began to winterize their outdoor seating by closing the spaces in for weather protection, and the use of tents and other structures to enclose outdoor seating increased. New guidance from the governor came out clarifying the requirements for outdoor dining structures and the deployment strategy changed again,  focusing on providing guidance and assessing compliance with outdoor dining requirements and protecting the health of customers and employees in outdoor spaces.

In early fall, with a focus on equity and recognizing the economic impacts of the response measures to the COVID-19 pandemic were having on the restaurant and hospitality industry, the SSTAR program recognized the need to provide financial assistance to help struggling businesses cover the increased costs associated complying with the COVID-19 prevention requirements. As many small businesses had incurred additional costs to implement certain COVID-19 prevention measures, such as to purchase sanitation and disinfectant supplies, masks, reconfiguration costs, outdoor dining expansion, etc. SSTAR obtained $500,000 in CARES Act Congressional Relief Funds, with $400,000 used to reimburse businesses for COVID-prevention expenses and $100,000 for the procurement and distribution of COVID-19 prevention and sanitation supplies. Federal funding normally requires extensive contract paperwork to distribute funds to businesses. Other local business grant programs relied on a 20+ page application and grant agreement, which would have significantly limited access to the funds by small and non-English businesses. To reduce this barrier, PHSKC developed a streamlined 2-page application and agreement, and translated all program information and forms into eight languages, distributing these at the same time as English-language versions.

According to WA State Department of Commerce, numerous aid and grant programs are available to help businesses (Director’s Update, September 2020). However, non-English speaking and business owners of color were far less likely to receive information about those programs even as they face disproportionately higher rates of closure due to the COVID-19 emergency.  At the same time, PHSKC found pronounced racial inequities among COVID-19 cases, hospitalizations and death, with higher rates in south Seattle and south King County (along I-5 corridor), and smaller concentrations in north King County and a pocket in northeast King County. These locations of higher rates of cases generally overlay with where there are larger concentrations of communities of color. (Public Health Insider, May 1, 2020)

The objective of this SSTAR Financial Assistance Referral Program was to provide direct financial assistance and supplies/equipment to locally owned small food establishments with the highest needs in King County to support them in implementing Safe Start guidelines.  A list of allowable expenditures and eligibility requirements were developed. In addition, the field teams that are working directly with food businesses to assist in meeting the COVID-19 measures will identify and refer eligible businesses for financial assistance.

With $400,000 available for direct financial assistance reimbursement, at a max of $3000 per business, the program supported 143 locally owned small food businesses with the greatest needs in high priority areas of King County. Financial assistance was in the form of reimbursement for expenses already incurred and for expenses required to meet the Safe Start requirements incurred between March 15, 2020, and December 30, 2020. During the SSTAR inspection, the inspector will work with the business owner to determine what equipment is needed to comply with the Governor’s Safe Start reopening requirements and the inspection report became the Scope of Work for the Grant Agreement.

Extensive communication outreach was an additional adaptation, and the aspect of the program we hope to sustain and incorporate into future post pandemic work. Information for food establishments on the COVID-19 requirements would be posted to the SSTAR website, which was developed to help support this response. Webinars in several languages were held, and informational fact sheets were translated into multiple languages. A list serve of establishments was developed and regular communication with them around changing requirements and resources was developed. Social media was utilized to highlight establishments that were doing well in following the governor’s orders. A mobile van was dispatched to different locations to provide educational handouts and food safety kits for food establishments, including hand sanitizer, masks, and gloves. Following a written communication plan to communicate with food establishments using a regularly updated contact list are activities we hope to continue after the COVID-19 pandemic is over, as modeled by the communication outreach efforts for the SSTAR program.  Another aspect of the SSTAR program we would like to continue is the interdisciplinary teamwork that was imperative to the success of the staffing of the effort.