Where: Palms Medical Group, a resident-staffed primary care clinic affiliated with Orange Park Medical Center in Orange Park, Fla.
The issue: Increasing rates for influenza and pneumococcal vaccination.
Palms Medical Group was established in 2015, and the physicians working there soon found that their patients were very likely to decline all vaccinations, of any kind, due mainly to concerns about safety or adverse effects, reported Sary O. Beidas, MD, FACP, associate program director for internal medicine residency. “Patients were saying, ‘We don't want this vaccine, period. We don't want to be vaccinated,’” he said. “And that made us start looking at our baseline rates.” Dr. Beidas also thought that focusing on immunization would be a good way for the residents who staff the clinic to dip their toes into the quality improvement (QI) pool.
To begin, Dr. Beidas and his team opted to work with ACP's “I Raise the Rates” initiative. He and two second-year residents, ACP Resident/Fellow Members Pragathi Balakrishna, MD, and Akshaya Kambhatla, MD, attended an information session with Marie T. Brown, MD, FACP, an associate professor at Rush Medical College in Chicago who is part of the faculty for the initiative, to gain insight on QI in general and immunization from an office-based perspective in particular.
“She's kind of like our mentor with this,” Dr. Beidas said. He noted that Dr. Brown's input through “I Raise the Rates” was particularly helpful because the guidance she provided on immunization helped augment his own experience with informatics. After the ACP training, Dr. Beidas and his team brought the principles they had learned home to apply to their project.
How it works
The vaccination team consisted of Drs. Beidas, Balakrishna, and Kambhatla, and Lisa Westby, LPN, who became the clinic's CVO, or chief vaccination officer. Once the intervention began in November 2016, team members held weekly meetings to analyze the group's immunization rates and evaluate what needed to be adjusted. In addition, all of the clinic's residents and nurses held a team huddle each morning to discuss the immunization status of the patients who were on the schedule for the day, and nurses were authorized to give vaccines to patients.
Since the clinic's patient population was known to be resistant to immunization, the project included role modeling of counseling techniques to better equip staff to address any objections. Feedback to the clinicians was also key. Immunization rates for influenza and pneumococcal vaccines were visible to all residents and nurses via a “run chart” that was updated weekly, giving senior physicians a talking point to keep immunizations near the top of the priority list.
“Each week, we would talk to them about why we're doing so good and maybe why we're not doing so good,” Dr. Beidas said. “Sometimes there were downs that we would notice, and we would talk with the residents, find out why, figure out if we could resolve the problem.”
For example, when a decline in immunizations was noted between weeks 2 and 3, the project leaders reviewed counseling skills with residents to help them overcome patients' objections. In addition, once Ms. Westby was appointed as CVO, she started individual conversations about vaccination with patients before they saw a physician, further helping to improve rates. The residents also made sure to be persistent in following up with patients, Drs. Balakrishna and Kambhatla said, making it more likely that those who declined vaccination during one visit would accept it with further counseling on a subsequent visit.
Before the QI initiative began, immunization rates for the clinic calculated over a two-week period were 38% among patients eligible for the influenza vaccine and 37% among patients eligible for the pneumococcal vaccine. After the three-month intervention, beginning in November 2016 and ending in February 2017, these rates were 57% and 62%, respectively. These improvements of 19% and 25% exceeded the goal of 10% established before the project began, Dr. Beidas said.
Some planned components of the project didn't prove feasible, Dr. Beidas said. “For example, we have a television monitor in the waiting room, and we wanted to have some dedicated programs that would address immunization so that patients, when they're waiting, they would watch something that is useful,” he said. However, technical challenges made this impossible, since streaming video wasn't available and the clinic's televisions didn't include video equipment.
In addition, Dr. Kambhatla noted that some residents in the practice were at first reluctant to stress immunization for all patients every time and would exclude some categories, such as people coming in for a preoperative evaluation. “We had to educate the physician to consider counseling or offering immunization at each and every visit,” she said.
In fall 2017, with a new flu season beginning, the clinic staff reviewed the results of last year's project and planned to build on them by involving more residents and holding more frequent QI conferences. All residents are now required to complete QI and patient safety certification, and Dr. Beidas hopes this will help boost QI efforts across the clinic.
“I think that's going to be a very important thing,” he said. “We're already beginning to see the residents come back and say they want to begin a QI project, given that they're already beginning to understand what QI is really all about.”
Words of wisdom
“One thing I would recommend on the road toward universal immunization is getting an order set so that prescribing [vaccines] bypasses the physicians,” Dr. Beidas said. “As soon as the patients come in and the nurses recognize that there is a need in the EMR, they just automatically give that.”