IQIP Strategies

On-time vaccination depends upon returning for subsequent doses as recommended in the Advisory Committee on Immunization Practices (ACIP) recommended immunization schedule. Scheduling the next visit before the patient leaves the office promotes adherence to the schedule by:

• Explicitly specifying when future doses are due and why
• Establishing continuity of care by supporting the patient’s return to the office
• Creating a commitment to return and reducing barriers to act on favorable intentions to vaccinate

Evidence Base and Justification

Ensuring that patients leave their appointment with their next vaccination appointment scheduled makes vaccination the default option. This takes the burden away from parents to remember to schedule an appointment later and removes the time and effort barrier for them to do so.

• A 2017 AAP clinical report asserts that making families aware of when vaccines are needed and scheduling follow-up appointments before they leave are crucial steps to increase adolescent vaccination rates.
• Studies from 2010 and 2016 of seasonal influenza vaccine uptake demonstrated the success of a variation of this ‘default vaccination appointment’ approach.

Scheduling the next vaccination appointment before the patient leaves the office can be combined with patient reminders and clear communication internally among provider staff and with parents about the ACIP immunization schedule.

Examples of strategy implementation activities

• Discuss future doses and emphasize the importance of receiving doses on schedule by using presumptive language.
• Provide information about future doses and reinforce the importance of staying on schedule by providing the parent with a personalized list of future vaccines with clear “on or after” dates.
• Schedule the next vaccination visits with the parent either immediately before or after vaccine administration.
• Give and/or send confirmation of the next appointment to the parent via text, email, or phone call
• Identify which workflow points where procedures will be revised for appointment scheduling or reminders

On-time vaccination depends on knowing what vaccines a patient is due for and when. High-quality data in the IIS can support providers by:

• Providing consolidated vaccination records for each patient
• Generating lists of patients due for vaccines
• Forecasting future dose due dates to assist with scheduling
• Delivering reminders for upcoming appointments
• Providing practice-based coverage assessments

Evidence Base and Justification

A functional IIS populated with timely and accurate data improves the efficiency of provider locations by giving them tools to ensure on-time vaccination, engage patients and their families, and monitor vaccine uptake. Providers can use this strategy to improve IIS data quality and to make use of features available within the IIS.

• A 2014 review of IIS-focused studies describes the wide variety of features IISs offer to improve provider workflow and vaccine uptake. For instance, providers can use the IIS to measure—and monitor trends over time in—vaccination coverage, and they can use this information to target areas for vaccination workflow improvement in general or for specific vaccines with lower uptake.
• Timely and complete IIS data also prevent over-immunization, as demonstrated by a 2015 study of influenza vaccination in children.
• Many IISs include provider reminder functions (also known as clinical decision support systems for immunizations, or CDSi), which generate notes and reminders alerting providers when patients are due or overdue for vaccination and forecasting upcoming vaccine due dates to assist with scheduling. The value of these features increases with the quality of IIS data.
• A 2021 review of studies on patient reminder and recall—which many IISs facilitate—concluded that reminder and recall is one of the most effective and cost-effective tools for both childhood and adolescent vaccine delivery.
• Another 2021 study highlighted the potential for centralized IIS-based reminder and recall to increase immunization rates nationally. Given the demonstrated success and low cost of this approach, this study concluded that wider dissemination should optimally involve state and regional IIS, especially given the willingness of IIS managers to engage in this effort.

Examples of strategy implementation activities

• Identify workflow points where procedures will be revised for looking up patient vaccination histories, vaccine forecasts, or generating patient lists.

• Enter new patients’ historical vaccination data into the IIS to more accurately determine which doses are due.
• Promptly enter all vaccine doses administered into the IIS, set up routine electronic reporting to the IIS, or work with the jurisdiction’s IIS team to improve existing EHR-IIS integration.
• Set up or fine-tune the IIS’s reminder and recall settings for vaccination appointments.
• Update patients’ active/inactive status in the IIS on a routine basis.
• Designate staff person to routinely run IIS-based coverage assessments to monitor provider immunization performance.
• Use information in IIS coverage reports during staff meetings and team huddles to identify opportunities for improving vaccination performance.
• Verify/update patient contact information for reminders, recall, and follow-up.
• Provide the parent with their child’s updated vaccination record and/or share information about the IIS’s public access portal (if applicable).

On-time vaccination is dependent upon parents choosing to vaccinate their children and adolescents. As parents’ most trusted source of vaccine information, health care professionals are well positioned to increase vaccine acceptance.

Evidence Base

Providers play a critical role in helping parents choose to vaccinate their child. Parents consider their child’s health care professionals to be their most trusted source of information when it comes to vaccines. This is true even for parents who are vaccine-hesitant or who have considered delaying one or more vaccines.

• Parents in a 2013 study were less likely to have concerns about vaccinating their child if they received vaccination information from their child’s doctor than if they received vaccination information from other sources.
• Results from a 2016 national survey of parents and adolescents showed that high-quality provider recommendations were positively associated with HPV vaccine uptake and negatively associated with refusal and delay.
• A 2011 study on low HPV vaccination rates found that a lack of provider recommendations contributed to under-vaccination. Providers trained to use the presumptive announcement approach for HPV vaccination saw greater increases in HPV vaccination coverage among their patients relative to coverage among control clinics in a 2017 randomized clinical trial.

Examples of strategy implementation activities

• Use presumptive language when giving a strong vaccine recommendation
• Prepare and practice responses to common parent questions and/or concerns about vaccination
• Arrange for provider education and any necessary training on the new approach

Myths and misinformation about vaccines put on-time vaccination at risk. Trust in vaccines is not built through a top-down approach, but through conversations between parents, doctors, nurses, pharmacists, and community members. Patients and parents can feel more confident about vaccinating when everyone in the practice shares the same message. From the front desk to the exam room to checkout, everyone plays an important role in supporting vaccination. Strengthening vaccine communications engages provider staff as vaccine partners by helping them:

• Increase positive vaccination messaging throughout their practice
• Provide accurate, easily accessible information on vaccines
• Engage in effective vaccine conversations with parents

Evidence Base and Justification

The messengers and messages used to convey accurate information about vaccines are important to combating misinformation and improving vaccine confidence. Prioritizing the use of clear, positive messaging about vaccination by all clinic staff creates an environment where patients and parents can have their concerns addressed and feel affirmed in their decision to vaccinate according to the ACIP immunization schedule. This strategy covers both internal communications including staff meetings and staff training to refine clinic workflows as well as external communications like websites, newsletters, and other patient-facing messaging.

• This continuing education module demonstrates how positive vaccine communication from nurses and medical assistants can play an important role in supporting vaccine acceptance.
• A 2017 study found increased on-time vaccination among infants whose parents were provided with web-based content about vaccines including social media options while pregnant.

Examples of strategy implementation activities

• Develop and implement a practice-wide vaccination policy.
• Include vaccine-related material (e.g., practice vaccination policy, ACIP immunization schedule, educational items, etc.) in new patient information packets.
• Direct questions to the appropriate staff should the parent have questions or concerns.
• Direct hesitant parents to sources of accurate, reliable vaccination information.
• Incorporate and routinely refresh vaccine-related content on the practice’s website.
• Plan and implement vaccine-positive posts on the practice’s social media accounts.
• Identify how everyone can play a part in supporting vaccination throughout the practice and review these steps during staff meetings and/or adding to staff training curriculum.
• Incorporate and routinely refresh vaccine-related content in the staff training curriculum (e.g., the ACIP immunization schedule, common questions and concerns about vaccines and how to address them, etc.)
• Create and monitor a feedback mechanism for staff members to ask questions or receive guidance on vaccines.