The Four Components of AFIX
The AFIX approach incorporates four key elements to improve immunization service delivery.
Click to expand each component
Assessment is the cornerstone of the AFIX process. Assessment refers to the evaluation of medical records to ascertain the immunization level for a defined group of people. This step, along with Feedback of the results, is essential in assessing a practice’s immunization rates. Accurate Assessments done in provider settings can identify overall coverage levels and pinpoint problem areas that the provider may not have known existed. It enables providers and their staff to make data-based decisions on how to improve performance.
The results from an Assessment can be used to guide strategies for improving immunization service delivery and office policies. Continuous, ongoing Assessments and follow up of performance are also essential in order to effectively monitor change in provider immunization services and practices. Assessment increases awareness.
The purpose of an Assessment is to:
- Quantify a provider’s vaccination coverage levels
- Identify opportunities for improvement of vaccination coverage levels and reduction of missed vaccination opportunities
CDC has developed an Assessment software known as CoCASA (Comprehensive Clinic Assessment Software Application). CoCASA is widely used and is instrumental for efficient and effective Assessments in provider offices. CoCASA can be downloaded from the NCIRD's Vaccines & Immunizations web site. The time necessary for the Assessment depends upon which Assessment method is selected and the quality of the record keeping practices at the provider office.
CDC recommends that grantees continue to work toward utilization of the Immunization Information Systems (IIS) for Assessment and toward ensuring that all provider immunization records are entered into the IIS. IIS functionality continues to expand. Population-based IIS will be the cornerstone of the nation’s immunization system. Responsibility for IIS development rests with state and local communities, with assistance from federal and state agencies, and private partners. With the increased IIS functionality comes the ability to execute population-based Assessments, utilize a Geographic Information System (GIS), and provide real-time interface with other data systems. This functionality and interface can streamline the process for Assessment of immunization coverage.
CoCASA provides detailed reports on the specific diagnosis of the problem, for example, whether children start their series on time, whether and when patients drop out of the system, and whether vaccines are given simultaneously. CoCASA can also help to raise awareness on issues such as record keeping and documentation and the need for reminder and recall systems.
Preparing for an Assessment
In order to conduct an accurate, reliable Assessment, issues such as how immunizations are documented, what type of record selection will be used, how to determine sample size and selection, and the development of Assessment working definitions need to be addressed prior to the actual Assessment process. Working definitions for "active clients" and children in the Moved or Going Elsewhere (MOGE) category, for example, should be established and agreed upon if comparisons are to be made to other provider sites. In general, standardized data collection allows for more accurate comparability among provider types within and between states. CDC has outlined several Assessment methods to assist public and private providers in assessing their immunization coverage levels. For technical details on planning and conducting provider Assessments, please refer to Assessment Methods.
Helpful Assessment Hints and Tips
Assessment requires not only the ability to interpret Assessment findings but also the ability to use observational skills to determine particular office processes that may be facilitating the administration of immunizations (strengths) or obstructing immunization administration (areas of opportunity).
Both measured and observed information should be presented to the provider during the Feedback process.
A significant amount of work is required to prepare for an Assessment and must be completed before arriving at the provider’s office. When you are finished with your Assessment make sure that you leave the work area clean and neat and leave the charts in a neat pile or re-file as agreed upon with the office staff.
Measured Information (Quantitative Data):
What are your Assessment findings?
- Coverage Levels
- Missed Opportunities
- Late Starts
- Valid vs. Invalid Contraindications
Observed Information (Qualitative Data):
What did you observe in the office?
- Immunization information available for patients?
- Immunization information clearly displayed for patients?
- Immunization schedule displayed in all exam rooms?
- Current ACIP schedule available to staff?
- Staff questioning parents on immunization status or reviewing immunization histories?
- Immunization telephone reminder service for patients?
- Other barriers to immunizations
What did you observe in the record review?
- Immunization records are comprehensive and easily visible in patient charts?
- Immunizations recorded in standardized place and method?
- Records well organized and legible?
- Immunization status assessed and documented at acute care encounters?
- Immunization electronic recall service for patients?
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After an Assessment
After doing an Assessment, there is a great deal of valuable information to be shared with practitioners and their staff. It is important to realize that assessments alone are not sufficient to improve immunization coverage levels. How we communicate the results of an assessment is just as important as how the data is measured. Assessment data coupled with Feedback provides the awareness necessary for improving immunization services by identifying useful changes in policy and practice as well as monitoring and refining interventions.
What is Feedback?
Provider Feedback is the presentation and discussion of Assessment findings to providers and their staff about their service delivery practices. Feedback of information can give the provider insight on record keeping practices, patient drop-out rates, missed opportunities, and inappropriate use of contraindications. The data should be presented with feeling and precision, without judgment, and as a challenge. The Feedback given should enable providers to identify problems, devise solutions, and set attainable goals.
Who Should be Included?
Feedback should include all those who can make a change, not only policymakers but also front line staff, providers, nurses, the clerical staff and office managers. Findings should be shared with providers in a constructive, timely and confidential manner, preferably as soon after the visit as possible. The data should not be sent to providers without explanation or analysis. Remembering the ultimate goal of the AFIX process is to improve and sustain immunization coverage levels, the Feedback protocol should:
- facilitate discussion among office staff
- assist providers and their staff in identifying problems and devising appropriate solutions
- encourage provider participation in goal setting
- support the use of continuous Assessments to monitor these goals
Helpful Feedback Hints and Tips
Providing Feedback to a provider and office staff is a combination of art and science. Possessing the knowledge and ability to analyze reports and condense the information into a simple and brief message is essential. In a Feedback session, you must be able to facilitate a discussion to motivate the practice to make changes to improve coverage.
- Be Prepared
- Organize your findings
- Outline your session
- What information will you share with the office?
- Focus on AFIX process vs. coverage level
- Begin and end on a positive note
- Focus on 2-4 priority areas
- Share with the provider and office staff strengths related to immunization delivery in the practice
- Introduce 2 to 4 areas of opportunity to improve coverage level
- Focus on areas that will provide the greatest benefit to the provider
- Priority areas must match provider’s priority and should be documented for follow up contact
- Establish a two way conversation
- Find out what the provider and staff think are the factors affecting the immunization coverage levels.
- What can they do improve or change these factors?
- Are these changes reasonable to implement?
- Who will take responsibility to make these changes?
- Use your interpersonal skills
- Maintain a positive attitude (non-judgmental)
- Connect with the staff- start to develop a relationship with office
- Confirm your understanding of what staff has said
- Gather your thoughts before responding
- Contact should be made with every provider who receives an AFIX visit no more than six months following the Feedback
- The purpose of the follow-up contact is to continue dialogue with the provider about quality improvement and discussing progress towards implementing follow-up action items based on the Feedback session.
After Assessment & Feedback
Once an Assessment is performed and Feedback is given, providers are then faced with the challenge of devising solutions to improve their immunization practices. While most health care professionals are motivated by an intrinsic desire to improve health care, extrinsic rewards, or Incentives, are often helpful. An incentive is something that incites or has a tendency to incite determination or action. Often times, incentive programs cannot only help providers move forward in achieving their immunization goals; they can also enhance performance over time.
Recognition is special notice or attention, a surprisingly powerful motivator. Incentives and recognition efforts should be aimed at all levels of involved personnel-providers as well as clerks, nursing staff, and office managers. This emphasizes the importance of a team approach in problem solving. All of those who participated in efforts to improve immunization coverage should be rewarded for a job well done. Good incentive programs offer something of value (e.g., professional recognition, attendance at a national or state conference).
Examples of Successful Incentives
- publication of successes in state/local newsletters
- paid immunization conference registration for office staff
Organizations for Sponsorship
- local businesses
- professional organizations
- managed care or HMOs
- vaccine manufacturers
Helpful Incentives Hints and Tips
Incentives are techniques used to encourage individuals or organizations to improve immunization services. Incentives are the "I" in AFIX and can range from inexpensive and simple to costly and complex. It is up to grantees to determine which Incentives would be most effective for each provider.
Factors that may influence the effectiveness of Incentives:
- Sources of Motivation
a. Intrinsic process; motivated by fun
b. Instrumental; motivated by rewards
c. Self-concept external; motivated by reputation
d. Self-concept internal; motivated by challenge
e. Goal internalized; motivated by cause
- Office Environment
- Priority level of immunizations in overall practice
Incentives can be categorized as informal or formal:
Informal Incentives can be low cost and simple and focus on interventions at individual providers and can also be part of the Feedback session. Some examples of Informal Incentives are:
- Immunization Resource Materials
- The most current VIS forms
- ACIP schedule
- Patient education material
- Web Site Information
- Your Knowledge and Experience
- Assistance in developing a realistic quality improvement plan to improve immunization coverage levels
Historically, this form of Incentive was promoted by the AFIX strategy in the
form of public recognition of improved immunization coverage levels.
Formal Incentives are generally more complex and expensive than
Some examples of formal Iincentives are:
- News articles written about best practices and high performing providers
- Tuition/paid registration to educational conferences
The eXchange Component
The eXchange Component
The eXchange component of AFIX can occur in conjunction with Feedback and Incentives or it can be an ongoing process of sharing information among providers. Once providers begin using strategies of Assessment and Feedback and are motivated to change behaviors and practices, they become more interested in learning more about the best ways to improve coverage. Information eXchange allows providers and their staff to educate their peers on what barriers they faced in implementing specific interventions and how they overcome those barriers to achieve success.
eXchange of Information
eXchange of information can:
- Inform providers about appropriate immunization practices and dispel any myths that may exist
- Promote the value of Assessment as a diagnostic tool
- Share ideas about what works and what doesn't work
- Create a sense of mutual support among providers
- Create a common mission among providers and public health
Helpful eXchange Hints and Tips
"Use Every Opportunity to eXchange Information"
Exchanging information successfully requires you to be knowledgeable about best practices related to improving immunization coverage levels and to be able to assist the office in identifying actions that would improve immunization coverage levels.
eXchange of information must be included in the Feedback session to assist the provider and office to develop a realistic quality improvement plan to improve immunization coverage levels. The eXchange of information can and should be presented in both an informal and formal manner:
Informal eXchange of information:
- Discuss during Feedback session what changes could be made in practice to assist in improving immunization coverage level
- Utilize your knowledge of what other practices with similar populations have done to improve coverage levels and what activities were successful. It is also important to discuss activities that were unsuccessful and their reasons.
Formal eXchange of information:
Historically, the eXchange of information has been presented as peer to peer provider discussion. This mentoring interaction between an "immunization champion" and another provider attempting to improve immunization coverage levels is considered the "gold standard" for eXchange of information.
Since it may take years to develop and implement the gold standard of an "Immunization Champion" exchanging information with other providers, you should take every opportunity to eXchange information on improving immunization coverage levels with providers and office staff.