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AFIX Site Visit Answer Guide

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Strategies to Improve the Quality of Immunization Services

Question Provider’s Response Recommended Assessor’s Response to the Provider’s Staff References/Additional Information
  1. Do you have a reminder/recall process in place for pediatric/adolescent patients?
NO or YES (but would like additional information)

Key Points:
According to The Community Guide, “Client reminder and recall (r/r) interventions involve reminding members of a target population that vaccinations are due (reminders) or late (recalls).”

The reminder component consists of messages (using phone, text, standard mail, e-mail, etc.) to remind parents or guardians of vaccination due dates for their children. Reminder messages can improve parents' awareness that vaccinations are coming due and the importance of scheduling and keeping appointments, therefore increasing the up-to-date vaccination status of pediatric/adolescent patients.

The recall component consists of messages (using phone, text, standard mail, e-mail, etc.) to parents or guardians of children who are past due for one or more vaccinations and encourages them to schedule an appointment with their health care provider or local health department. Recall messages can decrease vaccination drop-out rates and reduce the time children remain at risk for vaccine-preventable diseases.

Effective reminder/recall systems are conducted by clinic staff on a routine basis, and using a routine process. Clinics may choose to conduct r/r activities monthly, quarterly, or on some other schedule. R/R lists can be generated through the EHR, IIS, or using a paper-based “tickler” system.

The implementation of vaccination r/r systems has potential benefits beyond improved vaccination coverage rates. Patients of all ages who are due or overdue for recommended vaccinations also may have fallen behind in health supervision visits and may experience barriers to health care in general. Vaccination r/r systems may help identify patients who are at risk for not receiving comprehensive primary care.

Recommendations:
A clinic that is interested in conducting r/r should take the following steps:

  1. Determine which method of r/r is most appropriate. For many clinics, a paper-based tickler system is the best and easiest option. Clinics that would prefer to use their electronic health records (EHR) or immunization information systems (IIS) will need to research the system’s capacity to conduct reminder/recall.
  2. Use data to determine which patient population or vaccine to focus reminder/recall activities on.

Clinics should periodically measure the effectiveness of their r/r system to make sure it is having the desired effect. For example, clinics may choose to monitor the number of r/r notices sent and the number of patients who schedule appointments following receipt of an r/r notice, or the number of r/r notices that are returned because they are undeliverable. Clinics can use this information to tweak their r/r system so it has the greatest possible effect.

Summary of Task Force Recommendations & Findings
The Community Preventive Services Task Force recommends r/r interventions based on strong evidence of effectiveness in improving vaccination coverage:

  • In children and adults
  • In a range of settings and populations
  • When applied at different levels of scale from individual practice settings to entire communities
  • Across a range of intervention characteristics (e.g., reminders and recall, content, theoretical basis and method of delivery)
  • When used alone or with additional components

More information can be found at the following links:

  1. Do you offer walk-in or immunization-only visits?
NO or YES (but would like additional information)

Key Points:
Walk-in or immunization-only visits provide convenient vaccination services proven to improve access to immunizations.  Given busy parent and child schedules, convenient express services are helpful and appreciated.

The National Vaccine Advisory Committee’s “The Standards for Pediatric and Adolescent Immunization Practices” supports the need for vaccine-only appointments and at a time available for the working parent.

Offering appointments in the late afternoon, evening and on weekends is a best practice strategy.

Walk-in visits allow families to get immunized at a time that is convenient for them, without having to schedule ahead of time. Immunization-only appointments are effective because they are generally quicker than a complete well-child visit. Also, for families who pay out of pocket for health costs or who have copay or deductible, immunization-only appointments typically result in lower out-of-pocket costs.

The first pillar in the CDC-supported publication “4 Pillars Standing Orders Program Toolkit To Increase Child Influenza Immunizations” is Convenient Influenza Vaccination Services. The pillar recommends extended vaccination season and express vaccination services for convenience. Dedicated express vaccination clinics can be systematized for efficiency. For example, if a provider selects to implement a flu vaccine express service, they may offer flu-only vaccines at that express service and implement efficient flow systems (e.g., 1-2 minutes per patient) for check-in, screening, vaccination, and record keeping.

More information can be found at the following links:

  1. Do you routinely measure your clinic’s pediatric/adolescent immunization coverage levels and share the results with your staff?
NO or YES (but would like additional information)

Key Points:
If you currently measure immunization rates on a routine basis, congratulations! This is a great first step.

Raising staff awareness of coverage levels confirms efforts are working and points to where more can be emphasized, such as specific ages and vaccines.

Routinely measuring immunization rates allows clinics to understand the immunization issues that are unique to their clinic. For example, through routine measurement, some clinics may identify certain vaccines with lower coverage rates, root causes for missed opportunities, or certain age groups with lower coverage rates than others. Once clinics are aware of this, they can plan quality improvement interventions that are tailored to the needs of their clinic and their patients.

Routine assessments allow clinics to monitor trends over time and evaluate whether interventions designed to improve coverage rates are having the desired effect.

Many EHRs and IISs allow clinics to routinely assess immunization rates.

Recommendations:
Clinics that want to begin routinely assessing immunization rates should:

  1. Determine which system to use for this routine measurement (EHR, IIS, other).
  2. Determine schedule, and assign responsible staff.
  3. Determine patient population to assess.
  4. Use data to plan improvement activities.

As part of the CDC-supported publication “4 Pillars Standing Orders Program Toolkit to Increase Child Influenza Immunizations”, the third pillar, Enhanced Office Vaccination Systems, provides recommendations for office vaccination systems to reduce missed vaccination opportunities, which could have a large impact on vaccination rates. This strategy of making assessment a Standard Operation Procedure is recommended as a routine part of office visits.

More information can be found at the following links:

  1. Do you schedule the next vaccination visit before the patient/parent leaves the office?
NO or YES (but would like additional information)

Key Points:
Scheduling the next vaccination visit before the patient/parent leaves the office ensures that they have the opportunity to select a convenient time for their visit. Once appointments have been scheduled, many clinics make reminder phone calls a day or two prior to the visit. For most clinics, it is easier to track patients who schedule an appointment but do not show up than it is to identify patients who should have scheduled an appointment and did not.

It also affords the provider/practice the opportunity to provide notification about the importance of vaccination and convenient vaccination services that suit the time and availability of patients.

Recommendations:
If clinic does not schedule the next appointment before the patient/parent leaves the office but is open to the idea, help the clinic identify changes that can be made.

Does the EHR or scheduling system allow visits to be scheduled months in advance? If not, are changes possible?

Simple interventions, like directing patients to leave through the reception area, can be an effective way to get patients/parents to schedule the next visit before leaving the clinic.

 
  1. Do you contact patient/parent within 3-5 days when a well-child or immunization-only visit is a no-show and reschedule the visit as soon as possible?
NO or YES (but would like additional information)

Key Points:
Rescheduling patients within a short time period (3-5 days) of missing their visits not only provides a longer time frame for bringing them up-to-date on their vaccinations but it also stresses the importance of immunizations and catching-up on missed opportunities.

For more information on recalling patients, see information provided for Question 1.

Recommendations:
If clinic does not contact patients who miss appointments, help them identify steps to take to implement this. Who could do this work? How will missed visits be tracked?

 
  1. Do you have a system in place to schedule wellness visits for patients who are between 11-12 years of age?
NO or YES (but would like additional information)

Key Points:
A reminder card/call for the 11-12 year old patient will reinforce to the parent that the practice holds a high standard for protecting patients and the importance of the teen vaccines.

A system for scheduling patients who are between 11-12 years for a wellness visit enables providers to assess and administer vaccination services to an important adolescent age group for receiving ACIP recommended Tdap, HPV, and MCV vaccines.

Recommendations:
Many EHR or IIS systems can be used to run a list of active adolescents, or to run a list of adolescents who are due for immunizations. Encourage clinic to explore the options that are available to them.

Also, use other adolescent visits, like sick visits or sports physical visits, to screen for immunizations.

 
  1. Do you have an immunization champion at this practice that focuses on QI measures, reducing barriers, and improving coverage levels?
NO or YES (but would like additional information)

Key Points:
Immunization Champions can foster motivation and track progress toward goals. An immunization champion can have any role within a clinic. For example, an immunization champion may be a physician, office manager, clinical services coordinator, or medical assistant. No matter what role, an immunization champion will be most successful if there is institutional support for quality improvement.

Recommendations:
If the clinic has an immunization champion, make sure they have the support necessary (time, resources, and commitment) to fulfill duties around immunization quality improvement.

As part of the CDC-supported publication “4 Pillars Standing Orders Program Toolkit To Increase Child Influenza Immunizations”, the fourth pillar, Motivation — Office Immunization Champion Tracks Progress Towards a Goal, recommends having an immunization champion at a practice to foster motivation and track progress. A successful vaccination program includes an office immunization champion who tracks progress towards a goal. An immunization champion monitors progress by setting a goal that is a 20% - 25% increase over the previous year (either as percentage of children immunized or number of doses given), monitoring progress, and sharing progress with others.

  1. Do you regularly document vaccine refusals and reasons for refusals (parent choosing to delay, parent has vaccine safety concern, medical contraindication, etc.)?
NO or YES (but would like additional information)

Key Points:
Documenting parent refusal of vaccination supports risk liability and provides data that the vaccine was offered and that the parent of the patient refused.  When vaccines are refused due to request for limited injections, it is recommended that the parent is the major decision maker on which vaccine is not administered.

It is recommended that vaccine refusals be documented with every visit. Patients and parents should be informed about vaccine benefits and risks even if they refuse to vaccinate. Federal law requires that this communication include providing parents/patients with Vaccine Information Statements (VIS).

Recommendations:
If clinic does not currently track vaccine refusals, help them figure out the best system to do so.

Does the clinic use paper charts? If so, a paper refusal form is a good option.

Many EHRs and IISs also can track vaccine refusals.

Encourage providers to talk about the importance of refused vaccines and offer vaccination, even after a parent has signed a refusal.

More information can be found at the following links:

Additional information about vaccine refusals and alternate schedules:

“Within a 12-month period, 74% of pediatricians report encountering a parent who refused or delayed one or more vaccines. A 2011 survey of children 6 months to 6 years of age reported that 13% of parents followed an alternative vaccination schedule. Of these, 53% refused certain vaccines and 55% delayed some vaccines until the child was older. Seventeen percent reported refusing all vaccines. In a 2009 survey, 11.5% of parents of children 17 years and younger reported refusing at least one vaccine.” American Academy of Pediatrics, 2012.

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Strategies to Decrease Missed Opportunities

Question Provider’s Response Recommended Assessor’s Response to the Provider’s Staff References/Additional Information
  1. Does your immunization staff educate parents about immunizations and the diseases they prevent, even when the parents refuse to immunize?
NO or YES (but would like additional information)

Key Points:
Studies show that physician and other health care professionals’ recommendations are central to vaccine acceptance. Parents need to know about the importance of vaccination, the availability of vaccines, and the availability of convenient vaccination services.

Federal law requires that health care staff provide a VIS to a patient, parent, or legal representative before each dose of certain vaccinations. Vaccine Information Statements (VIS) are information sheets produced by the CDC that explain both the benefits and risks of vaccine to vaccine recipients.

According to the “4 Pillars Standing Orders Program Toolkit  to Increase Child Influenza Immunizations”:By providing education to parents about the importance of vaccination and the availability of convenient vaccination services at provider offices, your program would be implementing the second pillar for increasing childhood immunizations, Patient Notification.”

More information can be found at the following link:

  1. Do you have immunization information resources to help answer questions from patients/parents?
NO or YES (but would like additional information)

Key Points:
Messages notifying parents/patients about the importance of vaccination and the availability of convenient programs can be delivered via e-mail, Auto dialer (Audicare/Televox), on-hold messages, office posters, social media, public service announcements, and videos.  CDC has developed immunization information resources (including Vaccine Information Statements [VIS]) and outreach materials that can be made available for you to assist with your information/education efforts.

Recommendations:
If clinic does not feel they have adequate resources, help them find resources. This may include accessing materials developed by their state’s immunization program, accessing materials on the CDC or Immunization Action Coalition (IAC) website, or finding training opportunities.

More information can be found at the following links:

  1. Is your immunization staff knowledgeable and comfortable with current ACIP recommendations, including minimum intervals, contraindications, etc.?
NO or YES (but would like additional information)

Key Points:
Resources are available to help clinic staff that do not feel they have enough knowledge about the immunization schedule.

Stress that the practice wants to keep patients as protected as possible, therefore using the ACIP recommended schedule is optimal and endorsed by your practice.

For AFIX assessments and generating immunization coverage reports for practices, CDC requires following the ACIP recommendations on immunization schedules, including the list of vaccines to administer, minimum intervals between doses and ages for recommended vaccines.

Information is also published by CDC about vaccine-related contraindications and precautions. If your staff would like more information and/or a refresher course on the issues mentioned here, CDC would be happy to provide that.  

Recommendations:
Discuss training options that are available.

Most IISs and some EHRs have a vaccine forecaster that show which vaccines are due or past due. Use a forecaster in addition to clinical judgment to determine which vaccines should be administered.

If clinic does not currently use a forecaster, help them explore how to incorporate use of a forecaster into their workflow. For example, front desk staff can run a forecast for all patients scheduled at the beginning of each day.

More information can be found at the following links:

  1. Do you train front desk/scheduling staff so they know when it’s appropriate to schedule immunization appointments?
NO or YES (but would like additional information)

Key Points:
Front desk staff play a key role in making sure that appointments are scheduled appropriately, to avoid missed opportunities. Train the staff regularly on the importance of proper scheduling to lessen patient no-shows. Also train them on the current immunization minimum intervals and minimum ages to reduce invalid doses.

Training your front desk/scheduling staff to account for vaccine schedules when scheduling appointments and/or wellness checks can ensure that:

  1. Appointments and follow-ups are scheduled at an appropriate time for patients’ vaccine schedules
  2. Missed opportunities for vaccination are minimized
  3. Appointments and follow-ups are scheduled at convenient times for patients/parents.

Recommendations:
If a clinic identifies this as a problem, help them identify steps to provide training and/or change workflows to make sure appointments are scheduled in a timely fashion.

This training should occur regularly with staff and can assist with reducing invalid doses.

More information can be found at the following links:

  1. Do you have standing orders for registered nurses, physician assistants, and medical assistants to identify opportunities to administer all recommended pediatric/adolescent vaccines?
NO or YES (but would like additional information)

Key Points:
Standing orders authorize nurses, pharmacists, and other health care personnel (where allowable by state law) to assess a patient’s immunization status and administer vaccinations according to a protocol approved by an institution, physician, or other authorized practitioner. The protocol enables assessment and vaccination without the need for examination or direct orders from the attending provider at the time of the interaction.

In settings that require attending provider signatures for all orders, standing order protocols permit assessment and vaccination in advance of the provider signature.

Recommendations:
If clinic does not use standing orders, refer them to your immunization program’s or CDC’s standing orders.

Summary of Task Force Recommendations & Findings
The Community Preventive Services Task Force recommends standing orders for vaccinations are based on strong evidence of effectiveness in improving vaccination rates:

  1. In adults and children
  2. When used alone or combined with additional interventions
  3. Across a range of settings and populations

More information can be found at the following links:

  1. Is your immunization staff knowledgeable and comfortable with administering all recommended vaccinations to patients at every visit?
NO or YES (but would like additional information)

Key Points:
Patients/parents trust their health care providers as a valuable source of information about immunizations.

Providers and clinic staff should be knowledgeable and comfortable answering questions and concerns.

It is also recommended that providers empower their staff to vaccinate with standing orders programs.  Standing orders allow clinical staff, both nurses and medical assistants, to assess a patient’s eligibility for vaccine, and vaccinate per protocol without the need for an individual physician’s order. These recommendations should occur at all visits, sick or well. 

Recommendations:
If providers/staff are not comfortable administering all recommended vaccines or talking with parents who have concerns, help them find appropriate trainings or resources. Consider having experienced staff mentor less experienced staff.

More information can be found at the following links:

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Strategies to Improve Completeness and Accuracy of Immunization Information in the IIS

Question Provider’s Response Recommended Assessor’s Response to the Provider’s Staff References/Additional Information
  1. Does your staff report all immunizations you administer at your clinic (or practice) to your state/city IIS?
NO or YES (but would like additional information)

Key Points:
Introduce your IIS and its capabilities. Explain the importance of reporting all administered immunizations to this IIS to generate complete and up-to-date coverage assessment reports. If administered vaccines are not reported to IIS in a timely and complete manner, the coverage rates generated are not a true representation of the assessment coverage rates and missed opportunities for this provider under this AFIX assessment.

Not reporting all immunizations to the IIS can also provide inaccurate assessments resulting in over-immunization, which is costly.

Recommendations:
If clinic does not report doses to the IIS, provide them with information about how to sign up, training opportunities, etc.

Summary of Task Force Recommendations & Findings
The Community Preventive Services Task Force recommends immunization information systems on the basis of strong evidence of effectiveness in increasing vaccination rates.

More information can be found at the following links:

  1. Does your staff report immunizations previously administered to your patients by other providers to the IIS (official shot record, other IIS report, copy of medical record)?
NO or YES (but would like additional information)

Key Points:
Providers should report to the IIS all immunizations known to have been administered to a patient, regardless of whether the immunizations were administered by the provider’s office, or by another provider. This helps ensure that every patient has a complete, consolidated vaccination history in the IIS and that the provider’s coverage assessments reflect the true vaccination coverage for the patient population served.

Recommendations:
Show staff how to enter historical immunizations directly into the IIS, or how to submit doses through electronic data exchange.

 
  1. Do you inactivate patients in the IIS who are no longer seen by your practice?
NO or YES (but would like additional information)

Key Points:
CDC has defined business rules for assigning patients as “active” or “inactive” in the IIS.  The application of these business rules can have significant effects on the way the provider’s patient population is defined by the IIS and on a provider’s immunization rates. Maintaining accurate patient lists also makes other functions of the IIS, like reminder/recall, more accurate for the clinic. If the IIS has not implemented functionality for providers to designate patient status, the assessor should be prepared to discuss the immunization program’s alternative approach to defining the provider’s patient population.

Recommendations:
If clinic does not track patient status, take one or more of the following steps:

  1. Ask whether they have standard definitions of active/inactive patients within their clinic.
  2. Share active/inactive definitions used by other clinics.
  3. Help them decide whose role it is to maintain patient status, and create a work process to do so.
  4. Help them figure out whether patient status can be documented in the EHR.
  5. Help them figure out whether patient status documented in the EHR can be sent through data exchange to the IIS OR demonstrate how to change patient status directly in the IIS.

More information about the business rules for inactivating patients in IIS can be found at the following link:

  1. Do you use your IIS to determine which immunizations are due for each patient at every visit?
NO or YES (but would like additional information)

Key Points:
The immunization schedule is complex, and it is difficult to forecast, especially for a patient is not on a regular immunization schedule.

Many EHRs and most IISs have a forecaster that uses algorithms to determine which vaccines are due on the date of service. Forecasters should be used along with the patient’s medical record and the clinician’s judgment to determine what is due.

Enhanced office vaccination systems as defined by evidence-based strategies recommends assessment of vaccination by nursing staff as a routine part of a patient’s every visit. It is recommended that vaccination assessments be addressed as part of vital signs. Make assessment a “Standard Operating Procedure” for any patient visit; well or sick. IIS have the ability to generate a list of patients due for vaccination on the day of their visit and to provide an immunization forecast for individual patients. The accuracy of this information is dependent on the accuracy and completeness of the immunization data reported to the IIS. Assessor should explain the importance of reporting complete, accurate, and timely data to IIS. 

Recommendations:
If clinic does not currently use a forecaster, help them explore how to incorporate use of a forecaster into their workflow. For example, front desk staff can run a forecast for all patients scheduled at the beginning of each day.

More information can be found at the following link:

  • The National Vaccine Advisory Committee (NVAC) - The Standards for Pediatric Immunization Practice
    Standard 4:  Providers utilize all clinical encounters to screen and, when indicated, immunize children.
    Standard 9:  Providers use accurate and complete recording procedures.

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