Vaccination Performance Improvement How did it happen? Judy Gadke RN, MSN Clinical Case Management Specialist Saint Joseph’s Hospital Marshfield, WI January.

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Presentation transcript:

Vaccination Performance Improvement How did it happen? Judy Gadke RN, MSN Clinical Case Management Specialist Saint Joseph’s Hospital Marshfield, WI January 2007

Saint Joseph’s Hospital 500-plus bed tertiary care teaching hospital Only verified trauma center in north central Wisconsin Admit 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 Improvement Where did we start? Where are we now? How did we get there?

Pneumonia Core Measures

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 Improvement Intense Cause Analysis

Cause analysis Cause 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 improve, we must provide the people who want to do the right thing, with a tool/process that is user friendly and inherently has 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 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…..ineffective Add a reminder sticker for the MD and re- educate RNs and MDs….ineffective Intense 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. Enters the Multidisciplinary Work Team Pulmonologist, Infectious Disease MD, Phamacist, RNs from various work areas THE QUESTION: The vaccination process includes many steps and several disciplines, how can it be improved?

Performance Improvement cont. Enters the Nurse-driven vaccination standing order. Research has shown this to be the most effective method of increasing pneumococcal and influenza vaccination rates.

October 2002, Tommy Thompson, Secretary of Health and Human Services removed the Federal rule which required a specific physician order for pneumococcal and influenza vaccinations in facilities caring for Medicare and Medicaid patients.

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. 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? NO Is this the right thing to do? YES

Performance Improvement cont. Vaccination Standing Orders: o culmination of one year’s work o multidisciplinary work team o policy/procedure endorsed by Infectious o Disease Committee and SJH Leadership o approved by Medical Executive governing o body of SJH/Marshfield Clinic

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

Performance Improvement cont. Protocol implemented on October 4 th, 2004 o The 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 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 4 th, (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. Chart audits by PI abstractors in Nov-Dec 2004 Manual Chart audits in 2005 and 2006 Shared audit results with all nursing units Frequent reminders to nursing regarding trends found in floor rounds

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… 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? THANK YOU for your attention.