Presented by
Jose Cadena, MD- Asst. Professor, Infectious Diseases,UTHSCSA
Amruta Parekh,MD,MPH – Education Development Specialist, UTHSCSA
Work supported by UT System, UTHSCSA, IHI/Macy Foundation, VA
E ducating for Qu ality I mprovement & P atient S afety

• Describe the quality chasm in healthcare
• Identify our local efforts to narrow the chasm
• Illustrate spread of quality and safety principles at our institution using a QI project as a paradigm
E ducating for Qu ality I mprovement & P atient S afety

UTHSCSA
Jan Patterson, MD –Medical Director, Infection Control
Jose Cadena, MD – ID physician
Jason Bowling, MD - ID fellow
Amruta Parekh, MD, MPH – Educational Development Specialist
UHS
Beth Ann Ayala, MT(ASCP), MS, MBA, CIC - Director, Infection Control
Teresa Prigmore, MHA – Director, Employee Health
Priti Mody-Bailey, MD – CMO, Community Medicine Associates
Leni Kirkman – Director, Corporate Communications
Theresa Scepanski – VP Human Resources

• HCW with influenza can infect patients.
• Infectiousness begins 1 day before symptoms.
• Up to 50% of infections may be subclinical.
• Seasonal influenza vaccine is 70-90% effective in preventing infection in healthy adults and reduces absenteeism.
• ACIP, SHEA, and IDSA recommend immunization of all HCW.
• National average HCW vaccination < 50%.

Available at NIAID; http://www3.niaid.nih.gov/topics/Flu/understandingFlu/communityImmunity.htm
. Accessed on
10/14/2009

Previous seasonal influenza vaccination rates were
< 60% for University Health System (UHS)
– 58.8% 2008 -09 season
– 58.5% 2007-08 season
– 45.0% 2006-07 season

• UHS is a 500 bed tertiary care hospital
– Solid organ transplant program
– Hematology oncology unit
– Level 1 trauma unit
– Neonatal ICU

To improve the UHS employee seasonal influenza vaccination rate to 80% or more by
December 2009 at UHS for the 2009-2010 influenza season.
E ducating for Qu ality I mprovement & P atient S afety

• Interprofessional and multidisciplinary teamwork
• Brainstorming
• Getting the Board on board
• Process flow
• Cause & effect diagram
• Data collection
• Audit feedback
• Control chart, Pareto chart, Gantt chart
• Plan – Do – Study – Act cycle

• 80% was chosen as the goal because there is evidence of “herd” immunity at this level of vaccination.
• “Contacted” was defined as documentation received by employee health that the HCW received or declined vaccine.

Institution
Logistics
Hard to contact everyone
Vaccine & Side Effects
Afraid of getting flu from vaccine
Believe the vaccine is a guess
H1N1: How can they make it in 3 months
when usually takes a whole year?
Education
Not enough facts
Not educated about flu
Takes time to sway people
back to acceptance
Misconception about live vaccine
Lack of trust in people who make vaccine
Placebo effect
Egocentric individuals (only effect self)
Lack of time
TV always negative
Have never had the flu, so not concerned
Previous experience, cold or other illness after vaccinated
H1N1 Risk Population is changing
Only focuses on flu
during flu season
Hard to overcome individual beliefs
Vocal people sway others
Fear of side effects
Lack of knowledge
Object to putting substances
in their body
Core belief
Delay in shipments
Not priority to be knowledgable about vaccine
Peer Pressure
Past experience
Unit culture
Lack of buy-in
Don’t give time to staff
Don’t believe
Don’t get it
Don’t encourage
Lack of interest by leader
Executive leadership does not set example
Leader lacks leadership skills
Must go above and beyond
Lack of accountability
No ramifications to leader if staff not vaccinated
Lack audit/feedback
No ramifications to executive leaders
In 2008, 58.8% vaccination rate
Lack of peer pressure at this level
Lack of interest
People Leadership
All proceedings and records of the Quality/Risk Management Committee are confidential and all professional review actions and communications made to the Quality/Risk Management Committee are privileged under Texas and federal law.Tex. Occ. Code Ann. Chps 151 & 160; Tex Health And Safety Code §
161.032; and 42 U.S.C. 11101 § et seq.

Force Field Analysis
Goal: To increase the Employee Seasonal Flu Vaccination Rate from 58% to 80 % by
November 15th 2009, at University Hospital in San Antonio,TX
Driving Forces Restraining Forces
Current Employee Flu vaccination rate = 58%
UH management strongly suports the Employee Flu
Vaccination Inititaive →
← People Factors: Staff donot believe in getting vaccinated due to religious causes, lack of trust, mortality, complications
Immunization Clinic well staffed, knowledgable, updated on vaccination information →
← Peer /Unit pressure to resist vaccination
→
← Lack of time, institution only focuses on flu during Flu season
Strong vaccination campaign →
← Lack of education: not enough facts
→
←
↓
These forces resulted in low employee flu vaccination

•Interventions were prioritized using the
Focusing Matrix of importance vs. ease of intervention.
September – November 2009
•Audit/feedback data by unit
 Sent to unit directors & residency program directors in dashboard format
 made available on-line
E ducating for Qu ality I mprovement & P atient S afety

 Residency program directors provided documentation of residents vaccinated at affiliated sites.
 Volunteers recruited to increase access to vaccination on the units and at conferences
 Hospital educators promoted educational campaign.
• Follow up, October – December 2009
• Priority units of the hospital with low rates of vaccination were identified.
• Vaccine was redistributed to units as needed.
E ducating for Qu ality I mprovement & P atient S afety

• An influenza website, including FAQs and flu blog
• Photos of UH leadership getting vaccine on the website and in UHS newsletter.
• Weekly updates of rates by department posted on line and emailed to unit managers.
• Screen savers and telephone on-hold message.
• A letter from the CEO was sent to employees.

Department Name
Adult Medicine Clinic
All Housestaff
Anesthesiology-UH
CMA Clinic Operations-UFHCSE
Emergency Center
Environmental Services-UH
General Medicine
Hartman Surgical Pavilion
Labor & Delivery
Medicine Critical Care Unit
Neonatal Icu
Obstetrics
Obstetrics Clinic
Operating Room
Outpatient Surgery
Renal Dialysis-Outpatient UH
Renal Dialysis-UCCH
Special Surgery
Surgery Icu
Audit Feedback
Weekly Dashboard(10-11-2010)
35
64
89
143
113
96
83
Staff
10
741
14
51
29
38
101
104
52
26
120
28
Contact
10
380
14
51
35
54
87
142
105
92
82
25
33
101
102
45
26
107
26
% Contact
100.0%
84.4%
97.8%
86.5%
100.0%
89.2%
92.9%
100.0%
51.3%
100.0%
100.0%
99.3%
92.9%
95.8%
98.8%
86.2%
86.8%
100.0%
98.1%
% Vaccinated
70.0%
50.7%
78.6%
96.1%
81.1%
74.3%
64.6%
69.9%
80.0%
71.9%
86.5%
80.8%
92.3%
70.8%
89.3%
51.7%
71.1%
73.3%
80.8%

Nancy Ray, COO of UHS getting vaccinated

• From Sept. - December 1 2009, the seasonal influenza vaccination rate was 76.6%
(4271/5578).
• Of these 67.5% received vaccination at UHS,
9.1% received vaccination from other providers.
• Among the 92.4% contacted, 82.9%
(4147/5578) received vaccination and 863
(17.1%) declined vaccination.

• During the 2008-2009 influenza season, 81.9% of employees were contacted for influenza vaccination.
• Total vaccination rate was 58.8%: 54.4% accepted vaccination at UHS, and an additional 4.4% received vaccination outside
UHS.

• After interventions (September-November
2009),92.2% were contacted and the total vaccination rate increased to 76.6%, a 17.8% increase from the pre-intervention
period (OR 2.7, 95% CI 2.5-2.97, p: <0.01).

UHS HCW Influenza Vaccination Rate

0,35
0,30
0,25
0,20
0,15
0,10
0,05
Reasons HCW Declining Flu Vaccine at UHS
0,14
39,9%
0,09
65,2%
0,07
85,1%
0,05
60,0%
50,0%
40,0%
30,0%
20,0%
10,0%
0,0%
100,0%
90,0%
80,0%
70,0%
0,00
Fear of getting the flu Side Effects
Reasons
Doubt effective Contraindications

• Inter-professional QI team using QI tools significantly increased the HCW influenza vaccination rate.
– Narrowed the “knowing vs. doing” gap
• Vaccination rate still < 95%
• SHEA, IDSA, AAP recommending mandatory influenza vaccination in HCW

• Inter-professional QI team using QI tools significantly increased the HCW influenza vaccination rate.
– Narrowed the “knowing vs. doing” gap
• Vaccination rate still < 95%
• SHEA, IDSA, AAP recommending mandatory influenza vaccination in HCW

• Increase the employee flu vaccination rate to
> 85% for the 2010-2011 season
• Increase the rate of “contact” with those individuals that did not respond
• Emphasize education discussing those subjects that lead to declination
• Consider mandatory vaccination as now recommended by IDSA, SHEA, ACIP, AAP

• Recommended by the IDSA, SHEA .
• The BJC Healthcare experience:
– 26,000 employees, 98.4% were vaccinated and only 8
(0.03%) were terminated.
• The Hospital Corporation of America (2009):
– HCW of 163 hospitals, 112 outpatient centers and 368 physician practices. >140,500 employees !
– Vaccine or surgical mask during season
– Vaccination rate : Pre intervention (2008-2009): 58% vs 2009 96%
Babcock et al. Clin Infect Dis.;2010;50:459-464.
Cormier SB et al. Fifth Decennial International Conference on
Healthcare-Associated Infections. Atlanta GA, 2010.

1 . Molinari NA, et al. The annual impact of seasonal influenza in the US: measuring disease burden and costs. Vaccine 2007 Jun 28;25(27):5086-96.
2. Salgado CD, et al. Preventing nosocomial influenza by improving the vaccine acceptance rate of clinicians. Infect Control Hosp Epidemiol 2004 Nov;25(11):923-8.
3. Pearson ML, et al. Influenza vaccination of health-care personnel: recommendations of the
Healthcare Infection Control Practices Advisory Committee (HICPAC) and the Advisory
Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2006 Feb 24;55(RR-2):1-
16.
4. Caban-Martinez AJ, et al. Sustained low influenza vaccination rates in US healthcare workers.
Prev Med Jan 15.
5. Kohn KT CJ, Donaldson MS. To Err Is Human: Building a Safer Health System.
Washington,
DC: National Academy Press, 1999 .
6. Leape LL, Berwick DM. Five years after To Err Is Human: what have we learned? JAMA 2005
May 18;293(19):2384-90.
7. Hannah KL, Schade CP, Cochran R, Brehm JG. Promoting influenza and pneumococcal immunization in older adults. Jt Comm J Qual Patient Saf 2005 May;31(5):286-93.
8. Nowalk MP, et al. Improving influenza vaccination rates in the workplace: a randomized trial.
Am J Prev Med Mar;38(3):237-46.
9. Stewart AM . Mandatory vaccination of health care workers. N Engl J Med 2009 Nov
19;361(21):2015-7.
10. Loeb M et al. Surgical Mask vs N95 Respirator for Preventing Influenza Among Health Care
Workers A Randomized Trial . JAMA. 2009 ;302(17):1865-1871