Morris Regional Public Health Partnership A mini-collaborative with the NJ Collaborative for Excellence in Public Health Improving Documentation of Seasonal Influenza Vaccination in Childcare Settings

The Situation Annually 3, ,000 people die from seasonal influenza. 20,000 children are hospitalized annually with complications. Highly contagious, can cause high fever, pneumonia and make existing medical conditions (asthma) worse. Can cause dehydration and seizures in children.

The Situation New Jersey mandated influenza vaccinations in preschool and childcare settings in the influenza season due to vaccine shortage the mandate was lifted During the influenza season, that mandate was lifted, due to shortages of seasonal influenza vaccine and a focus on H1N1

The Situation During annual immunization audits in February 2010, public health nurses observed many children without any documentation of their seasonal influenza vaccination status. Little data existed other than some had documentation and some did not.

The Situation No plans were in place to consistently encourage the immunization of children against the flu and the subsequent documentation of that vaccine.

AIM STATEMENT By February 1, 2011 the rate of documentation of seasonal influenza vaccination status among preschool and childcare centers will increase from 57% to 80%.

Plan First step was to audit the schools to establish baseline documentation.

Plan Fishbone analysis to identify barriers and supports. Developed a sub- committee of public health nurses to gather data and develop a targeted project to design an intervention.

Fishbone Diagram

Do The committee developed a survey instrument for distribution to preschool and childcare center personnel, to help identify the barriers to documentation and their relative importance. The survey was piloted among a sample of 10 centers. It was revised and fielded via telephone to a total of sixty-two Preschool and Childcare centers. A 100% survey participation rate was achieved.

Do Barriers to influenza vaccination status documentation identified in the survey were: Uncertainty of state mandate requiring flu vaccine for children (73%) Inconsistency among parents in submitting documentation of vaccination, even when the vaccine was received (56% )

Do (Barriers continued) Concerns among parents about the vaccine’s safety and whether or not it was even necessary. (66% stated vaccine’s safety and 47% stated vaccine was unnecessary) 64% of the respondents cited access/availability of vaccine as an issue 25% cited inconvenience to schedule

Do Another contributing factor the forms used by schools to document vaccination status (generally referred to as IMM-8 or ‘yellow immunization cards’) were outdated. Lacked the visual trigger to follow up on influenza vaccinations.

Do 85% indicated that their local health department was a source of guidance and information 100% were satisfied with this source for information

Do Other barriers: Lack of understanding of the state. mandate and their legal responsibility. Lack of availability of childhood flu vaccine in fall For fall 2010, LHDs participating in this effort offered flu vaccine to children. Lack of knowledge and understanding of antigens and brand names of vaccines.

Do Based on the survey data obtained, a Tool Kit format was decided Upon and developed for Childcare Directors. The Tool Kit included: Sample IMM-8 as they should correctly be completed for each age group. Charts demonstrating the brand names and the antigens they contain. A separate chart listed the specific diseases and the brand names that covered them. Sample parent letters. Vaccine resources, including science-based information to address concerns of parents who are hesitant to vaccinate and to empower Center Directors to answer questions. New Jersey Communicable Disease Reporting Requirements.

Do Orientation was provided onsite to each Center Director by the Public Health Nurse.

Study An evaluation instrument was developed to measure the effectiveness of the Tool Kit. Public Health Nurses fielded this instrument in January 2011, via telephone to Center Directors.

Study The results of this evaluation process are below Data collected from the survey was extremely positive: 95% stated that they had used the Tool Kit 100% stated that they would use it again 85% stated that they used it as a reference when recording immunizations Tool Kit rated 94% in terms of clarity and 94% in terms of usefulness

Study The yellow section with immunization guidelines was the most valuable to them.

Study Comments from Preschool and Childcare Center directors: “It is a lifesaver” “Tool Kit is awesome… especially the vaccination combination names.” “Every Childcare center should have one of these. My sister centers keep calling me for questions because they know I have this Tool Kit” “I pull out this more than anything else” “Self explanatory…helped out with parents so I could explain what each kid needed”

Study Documentation of flu vaccination: 94%

Act Recommended changes based on results of the follow up survey and 2011 annual immunization audits: Health departments will send out reminder of State-Mandated influenza vaccine in October. Include a statement of the fines for non-compliance within the Tool Kit. ` Continue to measure documentation of seasonal influenza annually. If funds allow, continue to conduct pre-audits in November to encourage Preschool and Childcare Center Directors to document influenza.

Act Unanticipated Outcomes: Tool Kit addressed the broader picture of vaccinations, documentation and communicable disease reporting The Tool Kit received excellent feedback and peaked interest of Preschool and Childcare Centers. The process of surveying and one-to-one education strengthened relationships between LHDs and Preschools and Childcare Centers

Next Steps The Tool Kit will be modified as needed and made available on the Morris Partnership for Public Health website, at so that all childcare providers throughout Morris County can easily access it.

Team Members Kathy Gonzalez, East Hanover Township Health Department Helen Giles, Mount Olive Township Health Department Susan DeGraw, Pequannock Township Health Department Ginny Maico, Randolph Township Health Department Arlene Stoller, Morris County Office of Health Management Joan Swanson, East Hanover Township Health Department Colleen Hintz, Randolph Township Health Department Cindie Bella, Morris County Office of Health Management

Morris Regional Public Health Partnership A mini-collaborative with the NJ Collaborative for Excellence in Public Health Measuring Customer Satisfaction of Risk 2 and 3 Food Service Managers

The Situation The goal for the Morris Regional Public Health Partnership is to improve the quality of regulatory inspections of Risk Type 2 and Risk Type 3 retail food establishments. A Risk Type 2 food establishment has a limited menu. A Risk Type 3 food establishment has a menu requiring the handling of raw ingredients and complex preparation that includes the cooking, cooling, and reheating of at least three or more potentially hazardous foods.

AIM STATEMENT By March 2011, 30% of Risk Type 2 and Risk Type 3 retail food establishment operators located in the MLC3 region will rate their satisfaction with the regulatory retail food program by completing and returning a customer satisfaction survey. Source: F8&source=univ&ei=9Ew4Taa9BpSugQeIq4CjCA&sa=X&oi=image_result_group&ct=ti tle&resnum=1&ved=0CB8QsAQwAA&biw=1131&bih=572

Plan a fishbone diagram (next slide) to pinpoint barriers and supports for the process Develop aim statement Create sub-committee of REHSs Develop survey Pilot survey Administer survey Evaluate

Fishbone Diagram

Do Survey developed Organized survey into sections – timing – performance – rules – enforcement The purpose of the survey was to gauge the satisfaction of the retail food operators with the health department regulatory inspections.

Do In May, 2010, the draft instrument was pilot-tested on a small group of Risk Type 2 and Risk Type 3 retail food establishment owner/operators at Mount Olive Township’s food handler class. Based on the comments and problems identified with the instrument, appropriate revisions were made to the instrument.

Do The final survey, together with a cover letter and a self-addressed stamped envelope, was mailed to a total of 570 Risk Type 2 and Risk Type 3 retail food establishments in: East Hanover Township Mount Olive Township Pequannock Township Randolph Township (color coded to differentiate Risk Type 2 & Risk Type 3 retail food establishments). The mailing also included establishments that contract with these municipalities and are located within Morris County.

Study After the target survey response rate of 30% was reached, the survey data was entered into a computer-based survey instrument (Zoomerang) where each question was statistically analyzed.

Retail Food Establishments as Recorded on 12/31/2009 Total Risk 2/3Number Number Who MunicipalityEstablishmentsRisk #2Risk #3 Responded to Survey East Hanover Township Mount Olive Township Pequannock Township Randolph Township Total Percentage Responded23.50%22.73%24.08%36.80% Morris Regional Public Health Partnership QI Project 36

Study Key findings: The most significant finding was that over 50% of the retail food owners/operators were seeking additional food handler/safety classes to be offered for their employees

Retail Food Owner/Operator Satisfaction Survey: I would like the health department to offer a food safety class for my employees.

Study Team members were also able to identify from survey results whether they were performing a quality inspection, and whether or not the restaurant owners were acquiring useful knowledge from the inspection process.

Study Findings of the survey: Restaurant owners preferred inspections to be conducted at times when the establishment is not busy. Request for more food handlers classes.

Act Educate food establishments during inspections why they need to be inspected when busy. Pilot county-wide food handlers class.

Act In addition, the group will plan, develop and implement an on-line course in targeted languages for all food handlers interested in on-line training

Act The survey will be implemented yearly for ongoing customer satisfaction improvement.

Unanticipated Outcomes The involvement of REHSs from the four separate heath departments became advantageous, as all team members could provide useful information. By working collectively, the REHSs experienced the added benefit of gaining knowledge from each other, both for this effort and for other common work activities.

Next Steps The survey will be revised using a Likert scale and distributed to the remaining Morris County municipalities that have not yet participated Ongoing survey distribution to retail food establishments is likely, and additional surveys for other regulated entities is also being considered

Next Steps The REHS’s involved are considering implementing quarterly meetings for all REHS’s in Morris County since working with staff from the four health departments served to be a constructive addition to their profession.

Next Steps A comprehensive effort to provide food handlers education will be developed. This will include: – An in-class food handler’s course will be offered in English and Spanish to all interested food handlers

Next Steps An on-line food handler’s class, consisting of a comprehensive ‘Food Safety Training Manual’, pre and post-test, and final printable certificate upon passing the post-test.

Next Steps Distribution of the ‘Food Safety Training Manual’ during both regulatory inspections and during pre-operational inspections, so new food establishment owners/operators to gain food safety knowledge.

Team Members Kathy Nguyen, East Hanover Township Health Department Carl Reiners, Mount Olive Township Health Department Gail Gratzel, Pequannock Township Health Department Tim Zachok, Pequannock Township Health Department Stephanie Gorman, Pequannock Township Health Department Fatima Hurst, Pequannock Township Health Department Steve Widuta, Randolph Township Health Department

Morris Regional Public Health Partnership (MRPHP) Members Carlo DiLizia, Health Officer, President, MRPHP Mark Caputo, Health Officer,Vice President, MRPHP Peter Correale, Health Officer, Chairperson Program Committee, MRPHP Robert Schermer, Manager, MRPHP Carlos Perez, Health Officer, Morris County Office of Health Management Frank Wilpert, Health Officer, Mount Olive Township, Immunization Quality Improvement Project Leader

The Multi State Learning Collaborative Lead States in Public Health Quality Improvement is managed by the National Network of Public Health Institutes with support form the Robert Wood Johnson Foundation. Learn more about these activities at: