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Pneumococcal VaccinationAchieving 100% Compliance
Good Samaritan Health CenterJanuary 2007
Objectives
• Planning Stages– Data Analysis– Current State and Goals– Interventions
• Implementing Changes– Change Education
• Physicians• Nursing Staff• Other key stakeholders
• Monitoring Results– Data Analysis– Results Communication
Planning Stages
• Data Analysis
• Quarter 4 2004 Cumulative DataInpatient Pneumonia Vaccination Rates
0%
20%
40%
60%
80%
100%
Q3
20
02
Q4
20
02
Q1
20
03
Q2
20
03
Q3
20
03
Q4
20
03
Q1
20
04
Q2
20
04
Q3
20
04
Q4
20
04
Quarter
% P
ati
en
ts V
ac
cin
ate
d
Current State and Goals
• Current State (as of Q12005)– QI falling out badly
• 30 to 85% Compliance rate for 2004
– Using written notes to remind MDs• Physician overlooked; many times not addressed
• Goals– Create a consistent way for screening– Make it easy for the Physicians
• Physicians stated “too time consuming” to write out orders in charts
Interventions
• Create a label to easily assess vaccination status
• Add prompt on Admissions Database to attach label to front of chart
Interventions
Interventions
Interventions – Policy Creation
• During interview, RN asks vaccination questions• Patient Sticker adhered to Pneumovax Stickers• RN checks “did” or “did not” on sticker• Unit Clerk checks RECIN for vaccination status
– (Regional Early Childhood Immunization Network)• If Yes, Physicians signs #1 and #2
– #1 to Pharmacy, #2 on Progress Notes• If No due to previous vaccination
– #3 is signed and placed into the progress notes• If No due to Patient or Physician refusal
– #4 is signed and placed into the progress notes
Implementing Changes
• Physicians– Medicine Committee– Infection Control– Medical Staff Committees
• Nursing– Unit Meetings
• Other Key Stakeholders– Unit Clerks
Monitoring Results
• Data Analysis
Inpatient Pneumonia Vaccination Rates
0%
20%
40%
60%
80%
100%
Q3
20
02
Q4
20
02
Q1
20
03
Q2
20
03
Q3
20
03
Q4
20
03
Q1
20
04
Q2
20
04
Q3
20
04
Q4
20
04
Q1
20
05
Q2
20
05
Q3
20
05
Q4
20
05
Q1
20
06
Q2
20
06
Q3
20
06
Quarter
% P
ati
en
ts V
ac
cin
ate
d
Monitoring Results
• Data Analysis– Q12005 to Q32005
• Increasing Compliance• More work necessary
• Results Communication– Q12005 to Q32005
• Medical Staff Committee Meetings• Nursing Unit Meetings
Monitoring Results
• Data Analysis– Communication and Reiteration
• Q42005 to Current
– 100% Compliance
Summary
• Simple answers to tough questions– A small sticker goes a long way
• Analyzing processes to make them easier
• Meeting Physician needs increases compliance
• Any Questions???
