Changes

Protocolizing influenza and pneumococcal vaccination in the inpatient setting required a major change in culture that was facilitated by the support of our institution’s leadership. The project team’s commitment to partnering with providers, nurses, and pharmacists was key to our success as we were able to make rapid cycle improvements.

• Solicited opinions from Board of Pharmacy and Board of Nursing to ensure licensure compliance
• Requested formal endorsement from the Northeast Quality Improvement Organization (QIO) in order to gain acceptance from our medical community
• Amended our Rules and Regulations, Medical Staff Bylaws, to include “institutional standing physician orders”
• Gained support and buy-in through formal presentation of the program to Pharmacy and Therapeutics Committee, Nursing Leadership, Board of Trustees Performance Improvement Committee, Medical Executive Committee, Medical Quality Council, Physician Leadership Team
• Drafted two new institutional policies to support the new institutional standing physician orders for the two vaccines which defined screening criteria and authorized Registered Nurses (RNs) to enter the electronic order for the vaccine(s) without an individual provider’s prescription or signature
• Modified the Patient Health History and Assessment form to include “Immunization History”
• Modified electronic order entry rights of RNs to allow them to order the vaccines without an individual provider’s prescription or signature
• Created an electronic mechanism for providers to “opt out” individual patients from the institutional protocol
• Operationalized an electronic patient “Immunization Record” which maintains immunization history encounter to encounter
• Created “Immunization Wallet” cards for patients to facilitate communication of immunization status to other health care providers
• Created intranet site with program’s details
• Created a group email account to facilitate prompt response to thoughts, questions, and suggestions
• Developed print and electronic media campaign to kick off new program, “Up To Date? Vaccinate!”
• Developed educational posters for patients and families
• Developed educational posters for nursing staff
• Added program information to new nurse orientation
• Rolled out new program on two nursing units each week until full implementation was reached
• Communicated patient vaccine administration to Primary Care Physicians (PCPs) by fax notification
• Created daily electronic reports of vaccines ordered, given, and not given in order to give direct and immediate feedback to individual RNs during the early phase of implementation as a way of reinforcing standardized practice
• Distributed regular progress reports to upper management as well as to the entire nursing department
• Modified electronic order sets to fit needs of individual nursing unit based on feedback during their week of implementation
• Transitioned maintenance of program after first year from Center for Performance Improvement (CPI) to Epidemiology for long-term maintenance
• Developed annual media campaign to run each September
• Reported monthly progress on the electronic institutional Balanced Scorecard

Results

Summary of Results / Lessons Learned / Next Steps

The medical center increased compliance with the Influenza and Pneumococcal Vaccination Performance Measures for the CMS Core Measure Pneumonia from less than 20 percent to greater than 75 percent by successfully integrating an institutional immunization program into standard nursing practice that ensures adult inpatients are screened for influenza and pneumococcal vaccine status and that vaccinations are administered prior to discharge, if indicated.

Lessons Learned

Taking the time to gain widespread acceptance and passion for the project prior to implementation was key to this program’s success.  Publication of early results helped build and maintain momentum.  People became passionate about being part of the success story and actively sought out ways to improve the program.

• Generate organizational buy-in from the top down. Get the issue in front of the board of trustees who are in a position to leverage support from the medical staff.
• Appoint a project manager who is able to remove obstacles and break down barriers.
• Appoint nursing and physician champions who can generate passion for the topic with their peers.
• Allow ample pre-implementation planning to address regulatory and compliance issues. New policy development and approval often take time.
• Partner with the people who are most likely to be the biggest opponents early and address their concerns in an open and respectful manner.
• Meet opposition in the middle, don’t hesitate to make modifications to get early successes.
• Involve “boots on the ground” in program development. If the new process does not work for those individuals who are key to its success it will fail, and you will lose momentum.
• Define scope and be wary of “hitting the home run.” We were asked about including the emergency department (ED) and pediatric population in the program, but decided it was best to start with the adult inpatient population. We may decide to spread to the ED and pediatric population at a later time.
• Reward the efforts of even a few by advertising their success publicly and at every level of the organization, others will be eager to join in.
• Plan for long-term maintenance and annual media campaign to keep the program fresh.
• Measure and report progress at regular intervals and at all levels.
• Investigate performance dips quickly and thoroughly.
• Be prepared to modify the elements of the program yearly.
• Provide materials to each nursing unit; share a tip on how to manage the new forms by adding them to the admission paperwork packet. Make it as easy as possible for them to integrate the new process. Meet with the individuals managing the unit’s forms and give them a start-up supply.
• Appoint a visible “vaccine champion” who is seen as a staff advocate. The champion makes random visits to the nursing units in order to thank the nurses for their efforts, to share progress, and to elicit feedback about the process. This person also follows up on any issues that are identified and communicates back to the individual or unit with resolution.
• Flexibility during implementation is key acknowledge that any progress is better than no progress.

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