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  Assessment Feedback Incentives eXchange (AFIX)
An Overview of AFIX

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What is AFIX?

AFIX is a quality improvement strategy to raise immunization coverage levels and improve standards of practices at the provider level.  The acronym for this four-part dynamic strategy stands for

Assessment of immunization coverage of public and private providers, Feedback of diagnostic information to improve service delivery, Incentives to recognize and reward improved performance, and eXchange of information among providers.

The AFIX approach provides a quality assurance measure for public and private immunization providers, presents an excellent educational opportunity, encourages private and public partnerships, and increases awareness among immunization providers.

The assessment and feedback portions of the process are data-driven. The data help determine provider performance and act as a catalyst to improve and maintain coverage levels. Assessment of performance enables providers to determine how well they are doing through systematic, routine examination of client records. The data collected through these assessments can then be used to diagnose potential problems relating to service delivery and office policies.

AFIX starts with assessment. Presenting and discussing the assessment information is known as feedback. How feedback is done is key to the success of the process. Using the assessment data during the feedback session will help target practice areas that need to be improved. Strategies for improvement will then be specific to the practice, and their effectiveness can be measured during subsequent assessments.

The incentive and exchange phases of the AFIX process may include methods that stimulate competition among provider sites, encourage provider participation and mutual support, recognize successful solutions, and promote the exchange of results and ideas.

Background Information 

History of AFIX
In order to raise coverage levels to achieve national immunization goals, the Georgia Department of Public Health implemented a statewide program in 1986 that consisted of annual assessments of immunization records at its public health clinics. Information was fed back to clinic providers and their staff who, in turn, developed their own solutions to improve coverage.Incentives included rank order listings of clinics by coverage level, awards for sites with the highest levels, and presentations by successful clinics at annual immunization meetings. Other successful strategies included coordinating with WIC, conducting reminder/recall phone activities, and providing performance feedback to nursing staff. As a result of these efforts, immunization coverage levels in Georgia public clinics increased from 40% to 91% between 1986 and 2001. This intervention has become a national model program to improve immunization rates.

Effectiveness of AFIX
AFIX is widely supported as an effective strategy to improve vaccination rates. Many states have shown gradual and consistent improvement in their public sector coverage levels. Assessment and feedback of public and private provider sites are recommended in the Standards of Pediatric Immunization Practices issued by the National Vaccine Advisory Committee (NVAC) as well as the Advisory Committee on Immunization Practices (ACIP) in a statement endorsing the AFIX process and recommending its use by all public and private providers. The purpose of AFIX is to move health care personnel from a state of unawareness about the problem (low immunization rates in their practice) to one in which they are:

  1. aware, concerned and knowledgeable
  2. motivated to change
  3. ready to try new behaviors/strategies
  4. capable of sustaining these new behaviors.

The benefits of measurement and feedback are not confined to public clinics. In a private sector study of pediatric practices conducted by CDC and the AAP, the median up-to-date coverage for 4:3:1 at 24 months of age increased from 78% to 87% in one year. Similar improvements were seen over a 5 year period in community /migrant health centers that participated in a continuous quality improvement initiative; health centers in 10 states increased their levels for the 4:3:1 immunization series from 54% to 84% between 1996 and 2000. The research suggests that implementation of feedback strategies to improve vaccination rates can influence provider practices in other preventive services such as anemia and lead screening. Publications describing implementation, outcomes, and research issues of AFIX are available on this website.

The Need for AFIX
Although vaccine-preventable diseases are at their lowest point ever, variations in coverage levels exist in all age groups; “pockets” of under-immunized populations can be found in many urban and rural areas, particularly in those below the poverty level. Since nearly 98% of American-born infants begin well-child care in the U.S., it makes sense for public health to focus on providers. Provider-based strategies, such as AFIX, focus on sustainable improvements in service delivery. One provider who sees many clients can effect long lasting improvements in immunization practice. In addition, it has been said that only those who provide care can, in the end, change care. Thus, it is vital to direct interventions to improve service delivery towards health care providers.

Blend of Art and Science
The science of AFIX utilizes data collection and analysis of the assessment data. The art of AFIX challenges the provider staff as well as the assessment staff to interpret, communicate, plan, and implement strategies that improve immunization coverage.


In summary, AFIX is a quality assurance tool that consists of assessing the provider’s vaccination coverage levels, feeding back that information along with recommending strategies for improvement, providing incentives to the provider to improve vaccination levels, and exchanging information among the providers within the community about performance and best-practices. This quality assurance measure is a proven and reliable tool for improving vaccination coverage levels in provider offices.

The AFIX approach incorporates four key elements to improve immunization service delivery:

  • Assessment of immunization coverage of public and private providers
  • Feedback of diagnostic information to improve service delivery
  • Incentives to recognize and reward improved performance
  • eXchange of information among providers

For Detailed Information:

Core Elements of AFIX Training and Implementation
(print only version (.pdf)
(text-only version)

Assessment Feedback Incentives eXchange (AFIX)
AFIX Home | Overview | AFIX Publications |  Annual Report Results | Contact Information

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This page last modified on November 12, 2003


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