Vaccination Performance Vaccination Performance ImprovementImprovement

How did it happen?

Judy Gadke RN, MSNClinical Case Management Specialist

Saint Joseph’s Hospital Marshfield, WI

January 2007

Saint Joseph’s HospitalSaint Joseph’s Hospital

500-plus bed tertiary care teaching hospital Only verified trauma center in north central Wisconsin Admit 1200-1500 patients monthly More than 350 Marshfield Clinic physicians on medical

staff More than 2300 employees Member of Ministry Health Care Founded over 110 years ago by the Sisters of the

Sorrowful Mother

Performance ImprovementPerformance Improvement

Where did we start?

Where are we now?

How did we get there?

Pneumonia Core MeasuresPneumonia Core MeasuresSaint Joseph's Hospital - Marshfield: Quality Indicators through September 2006

Indicator Benchmarks1 % oxygenation assessment 99% 100% a 100% 100% 100% 100% 100%2 % pneumococcal vaccination 68% 93% a 78% 94% 100% 88% 85%3b % blood culture in ED prior to first antibiotic N/A N/A d N/A N/A 89% 79% 84%4 % adult receiving smoking cessation 84% 100% a 97% 98% 100% 95% 100%5b % receiving antibiotics within 4 hours 76% 91% a 75% 78% 86% 90% 91%6b % Non-ICU receiving antibiotics within 24 hours 86% 94% a 91% 92% 90% 100% 86%7 % influenza vaccination 50% c 81% 92% 94% N/A N/A9 % not readmitted within 30-days 95% c 98% 97% 96% 99% 97%10 % Discharge Alive observed (no risk adjustments) 92% c 97% 94% 91% 94% 84%C % Compliant in PN 1, 2, 3b, 4, 5b, 6a, 6b 68% c N/A 60% 78% 74% 74%

Pneu

mo-

nia (P

N)

200620052004

Performance Improvement cont.Performance Improvement cont.

Education…….ineffective

Re-education…ineffective and frustrating

Re-re-education…and add a paper reminder…ineffective, frustrating and a waste of time and paper!

Performance ImprovementPerformance Improvement

Intense Cause Analysis

Cause analysisCause analysis

Review all outliers for vaccination core measures

Look for trends…a person, a particular group of people, a unit, a department OR is it the process?

Many times it is the process…after all, most people come to work with the intention of doing the right thing!

SO, if we want the outcomes to SO, if we want the outcomes to improve, we must provide the improve, we must provide the

people who want to do the right people who want to do the right thing, with a tool/process that is thing, with a tool/process that is user friendly and inherently has user friendly and inherently has

very few weak links.very few weak links.

It is an added bonus if research has already proven certain methods/processes which may be a potential “fix” for your system to be successful!

Cause analysis contCause analysis cont..

Pneumococcal and influenza vaccinations RNs are not consistently assessing the

vaccination status despite the fact it is part of the admission assessment process.

MDs are not ordering vaccinations for eligible candidates.

What shall I do??

Performance Improvement cont.Performance Improvement cont.

Education…..ineffectiveAdd a reminder sticker for the MD and re-

educate RNs and MDs….ineffectiveIntense cause analysis: too many

opportunities for failure in the noncomprehensive process

Remember: Most people come to work with the intent to do the right thing!

Performance Improvement cont.Performance Improvement cont.

Enters the Multidisciplinary Work Team Pulmonologist, Infectious Disease MD, Phamacist, RNs from various work areasTHE QUESTION:The vaccination process includes many

steps and several disciplines, how can it be improved?

Performance Improvement cont.Performance Improvement cont.

Enters the Nurse-driven vaccinationstanding order.

Research has shown this to be the most effective method of increasing pneumococcal and influenza vaccination rates.

October 2002, Tommy Thompson, October 2002, Tommy Thompson, Secretary of Health and Human Secretary of Health and Human

Services removed the Federal rule Services removed the Federal rule which required a specific physician which required a specific physician

order for pneumococcal and order for pneumococcal and influenza vaccinations in facilities influenza vaccinations in facilities caring for Medicare and Medicaid caring for Medicare and Medicaid

patients.patients.

Performance Improvement cont.Performance Improvement cont.

Literature review: What questions need to be included in the

vaccination eligibility assessment? When should the assessment piece be

completed?When should vaccination(s) be given?

Performance Improvement cont.Performance Improvement cont.

Institutional assessment:Is this too labor intensive for our nursing

staff? …..Time motion study results: NO Can we garner support from nursing and

physicians?…..I hope so.Does anyone have a better idea? NOIs this the right thing to do? YES

Performance Improvement cont.Performance Improvement cont.

Vaccination Standing Orders:o culmination of one year’s worko multidisciplinary work teamo policy/procedure endorsed by Infectiouso Disease Committee and SJH Leadershipo approved by Medical Executive governingo body of SJH/Marshfield Clinic

Performance Improvement cont.Performance Improvement cont.

Computer-based training program written, tested, re-worked and then completed by nursing staff and pharmacy

Performance Improvement cont.Performance Improvement cont.

Protocol implemented on October 4th, 2004

o The 1-2-3 of how the vaccination standing orders work 1- on admission the admitting RN assesses the immunization status of all

adult patients (except birth center) by completing the on-line vaccination assessment, if eligible for a vaccine a printout is generated in the pharmacy.

Walking vaccination audit rounds carried out a few afternoons per week with chocolate rewards for those nursing staff in compliance, and personal written reminders to those not in compliance.

Performance improvementPerformance improvement

2- Pharmacist enters the vaccination(s) into the med administration guide.

3- On the patient’s day of discharge, the RN notifies pharmacy to send the vaccine(s), the RN instructs the patient regarding the vaccine, and administers the vaccine(s).

After implementation:

Protocol was implemented on October 4th, 2004. (same day the national flu vaccine shortage was announced).

Within a week vaccination audit rounds were carried out a few afternoons a week with chocolate rewards for those nursing staff in compliance and personal written reminders for those not in compliance.

Performance improvement

Performance Improvement cont.Performance Improvement cont.

Chart audits by PI abstractors in Nov-Dec 2004

Manual Chart audits in 2005 and 2006

Shared audit results with all nursing units

Frequent e-mail reminders to nursing regarding trends found in floor rounds

Performance Improvement cont.Performance Improvement cont.

Small educational posters for all units involved.

Need continuing surveillance and feedback to maintain the gain and to continue increasing compliance.

Important reminders…Important reminders…

Audit and report results to those involved in the process.

Rework process if necessary, include those who are actually carrying out the process in the rework phase too

Re audit after implementation, share results with those involved.

…………the process continues…….

Any questions?Any questions?

Any Questions?Any Questions?

THANK YOU for your THANK YOU for your attention.attention.