Los Angeles Restaurant Grades Lower Illness While Boosting Awareness and Consumer Engagement

Los Angeles County can point to data to show the effectiveness of the restaurant letter grade system, but public health officials admit they want more robust data.

While Los Angeles County’s move to adopt Hazard Analysis and Critical Control Point Principles to Risk-based Retail and Food Service Inspections should help, it’s a reminder of “how much we need evidence in public health and better data,” notes Betty Bekemeier, PhD, MPH, a University of Washington Associate Professor of Psychosocial and Community Health.

That’s beginning to change with Public Health Practice Based Research Networks and other efforts, says Bekemeier, who recently authored a study in the American Journal of Public Health showing that higher spending on food safety measures are correlated to lower rates of foodborne illness. A goal of the study: to show policymakers that public health investments yield good returns.

After getting food poisoning from a Newport Beach, Calif., restaurant, Southern California restaurant critic Brad A. Johnson declared in the Orange County Register that had Orange County adopted the same restaurant letter grading system that nearby Los Angeles County put in place in 1998, he would not have gotten sick. Wrote Johnson, “If this restaurant had opened in Los Angeles instead of Newport Beach, it would have to display a letter grade of C, or possibly B, in the front window – and I never would have dined there.” 

Almost two decades ago, the nation’s most populous county, Los Angeles, instituted an innovative school-like letter rating system for what today totals more than 25,000 restaurants. The effort to publicly grade food establishments—and require restaurants to post their most recent health department inspection results in the form of a letter grade in their front window—has contributed to safer food facilities in the county, reduced foodborne illness hospitalizations by about 20 percent,  and according to the Los Angeles Department of Public Health officials, has improved consumer information and created a cultural awareness of food safety. The Department conducts nearly 50,000 restaurant inspections each year. 

“There isn’t anyone in Los Angeles County who doesn’t know what an A, B or C is,” says Terri S. Williams, REHS, Assistant Director of Environmental Health at the LA County Department of Public Health. Restaurant letter grades have become part of the culture in LA County. Patrons regularly check restaurant letter grades before dining, and in late 2013, the user-reviewer website Yelp made that easier when it incorporated LA County restaurant letter grades into its reviews. Letter grades “increase the awareness of food safety everywhere, and that’s a big plus,” notes Williams.

Los Angeles County initially turned to letter grades in a further step to reduce foodborne illness, which each year sickens roughly 1 in 6 Americans (or 48 million people), hospitalizes 128,000 and kills 3,000, according to the Centers for Disease Control and Prevention. About half the foodborne-disease outbreaks nationally occur at restaurants and commercial eating establishments. In the six years prior to LA County’s letter grade system, foodborne-disease hospitalizations increased in the county, and ran 20 percent higher than the rest of California. One-third of California’s restaurants are located in LA County, according to the California Restaurant Association.   

Letter grades have had an impact. A 2005 Journal of Environmental Health study found that foodborne illness hospitalizations dropped by nearly 19 percent in the first year letter grades were implemented. Researchers attribute 13 percent of the decrease specifically to the grades. The decrease was sustained in following years. Stanford University and University of Maryland researchers also found that letter grades reduced hospitalizations by 20 percent, and further found that while only about 25 percent of LA County restaurants would have earned an “A” prior to 1998, more than 50 percent did in the first year letter grades were implemented.  

For restaurants, the letter grades can be a badge of honor or a Scarlett Letter. With the grades, consumers vote with their feet. Research shows shortly after letter grades started, Los Angeles’ A-rated restaurants earned an average of 5.7% more revenue than before 1998, while revenue among B-rated restaurants remained flat, and dropped by 1% for C-rated establishments.   

“Letter grades have opened a whole other element in our efforts to make food safety more effective,” says Williams. In essence, letter grades give officials another arrow in the quiver to battle foodborne illness. LA County continues to build on its letter grade success. In the past few years, the County aligned its inspections with the State inspection report, which provides several benefits, mainly uniformity, not only for regulators but for industry entities with operations up and down California. 

Going forward, the health department wants to work with industry to get ahead of potential problems, by supporting chain restaurants in employee training, working with corporate offices to identity outliers among their restaurants, or helping them improve certain food-preparation practices. 

At least six other BCHC jurisdictions have established and implemented a restaurant letter grading system, including: Atlanta (Fulton County), Chicago, New York, Phoenix (Maricopa County), San Francisco, and San Jose (Santa Clara County), CA.