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The Four Components of AFIX

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

Click to expand each component

1. Assessment of the healthcare provider's vaccination coverage levels and immunization practices

Assessment Component


Assessment is the cornerstone of the AFIX process. Assessment refers to the quantitative and qualitative evaluation of immunization records to ascertain the immunization level for a defined age cohort of children (0-18 years). 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:

  1. Evaluate a provider’s vaccination coverage levels and immunization practices
  2. Identify opportunities for improvement of vaccination coverage levels and reduction of missed vaccination opportunities.

Assessment Tools

CDC recommends that awardees continue to work toward utilization of the Immunization Information Systems (IIS) as the main source of data 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.

CDC also developed Assessment software known as CoCASA (Comprehensive Clinic Assessment Software Application). 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. 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.

CDC also developed an online system to be used for tracking and managing AFIX site visit data. This online system; AFIX Online Tool, is available for all awardees that use IIS as their main source of data and calculate coverage directly in IIS or using CoCASA.

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 Reminder

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.

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2. Feedback of results to the provider along with recommended strategies to improve processes, immunization practices, and coverage levels

Feedback Component

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 quality improvement strategies, 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:

  1. facilitate discussion among office staff
  2. assist providers and their staff in identifying problems and devising appropriate solutions
  3. encourage provider participation in goal setting
  4. support the use of continuous Assessments to monitor these goals
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3. Incentives to recognize and reward improved performance

Incentives Component

After Assessment & Feedback

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 awardees to determine which Incentives would be most effective for each provider.

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
  • coalitions
  • professional organizations
  • managed care or HMOs
  • vaccine manufacturers

Factors that may influence the effectiveness of Incentives:

  1. 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
  2. Office Environment
  3. Priority level of immunizations in overall practice

Incentives can be categorized as informal or formal:

Informal Incentives:

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

Formal Incentives:

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 informal Incentives.

Some examples of formal Incentives are:

  • News articles written about best practices and high performing providers
  • Tuition/paid registration to educational conferences
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4. eXchange of healthcare information and resources necessary to facilitate improvement

The eXchange Component

The eXchange Component

The eXchange of information is a component of the AFIX program aimed at following up with providers to monitor and support progress toward implementing the quality improvement strategies discussed during the feedback process. This exchange is necessary to ensure that quality improvement in standards and practices is taking place at the provider level.

The follow-up (X) process ensures not only continuous quality improvement, but that providers also have the necessary resources and information to improve the quality of their immunization services. The eXchange of information is a two-level process:

Level 1 - Initial eXchange of information (X):

Every provider that receives an AFIX visit receives an initial follow-up no later than six months following the feedback session. The purpose of this follow-up is to discuss and document a provider’s progress in implementing the agreed upon QI strategies and to provide any clarifications and technical assistance. The discussion should be based on findings from the latest AFIX visit and the agreed upon QI strategies.

Level 2 - Subsequent eXchange of information:

This is a continuation of the initial follow-up process and requires that additional contact be made with providers to continue assessing QI progress resulting from the latest AFIX visit.

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Guidance Documents

Be sure to consult the AFIX Policies and Procedures Guide and its associated documents for more information about Assessment and when providing AFIX education and training in any health care setting, whether public or private.)