Quality Improvement Work Plan
Task 1.c Influenza Vaccination
Project Lead
Chris Scalamandre, RD, CDN, Quality Improvement Coordinator
Project
Description
To maintain the number of Network 2 ESRD patients who receive annual vaccination for
influenza. CMS identified the need for increasing influenza vaccination as a “breakthrough”
initiative in 2005 and has set a goal to increase influenza vaccination rate to 90% by 2020.
Influenza (flu) is a contagious respiratory disease that can be spread from person to person prior
to and after the onset of symptoms through droplet contamination. According to the Centers
for Disease Control and Prevention most people who get the flu recover completely in one to
two weeks, but 200,000 people develop serious and potentially life threatening complications
requiring hospitalization and about 36,000 die each year from the flu.
Background
People of any age group can get the flu but rates of infection are highest among children.
Serious illness and death is highest among persons 65 and older, children under 2 and persons
with medical conditions that put them at higher risk for complications. Ninety percent of
deaths attributed to influenza occur in adults over 65 years of age. ESRD patients are at a high
risk for developing complications from influenza. In 2010, this population nationally had 43.4%
of their patients over the age of 65. Of this ESRD population 44.1% had diabetes, 28.1% had
hypertension, and the patients had an average of 4.2 comorbidities each. In Network 2 the
ESRD population had 48.3% of the patients over the age of 65, 41% had diabetes, 25% had
hypertension, and the patients had an average of 4.6 comorbidities each.
Annual influenza vaccination is the most effective method for preventing the flu and its
complications. The Healthy People 2020 goal is to increase the number of influenza
immunizations given. The Healthy People 2020 goal is to increase the number of influenza
immunizations to greater than 90% for persons aged 65 years and older, for persons who have
high-risk conditions, such as kidney disease and are aged <65 years, and for health care
professionals. The vaccine should be provided to all persons who want to reduce the risk of
getting the flu but emphasis on high risk group include children 6 months to 18 years, persons >
50 years and adults at risk for medical complications from the flu. The CDC states that 83% of
the US is in 1 or more of the targeted groups but < 40% of the US population received the
influenza vaccine during 2007-2008. In the 2006-2007 and 2007-2008 influenza seasons,
estimated vaccination coverage levels among adults with high-risk conditions aged 18-49 years
were 25% and 30% respectively. The ESRD patient population is considered a high-risk
population and it is recommended that every patient get vaccinated. In 2007 United States
Renal Data System (USRDS) reported that 59.4% of ESRD patients received flu vaccine
nationally. At that time, there was no Network-specific data for flu vaccines given. In 2008
United States Renal Data System (USRDS) reported that 62.4% of patients received the flu
vaccine nationally, up 3% from the year before.
On April 15, 2008 the final rule for the Conditions for Coverage (CfC) for ESRD Facilities was
published. In the CfC it states that the patient assessment must include an immunization
history and the quality assessment and performance improvement program must develop
recommendations and action plans to promote immunizations. The influenza vaccination
project was selected by the MRB in CY 2008 to support the requirements of the CfC, the goal
of the Healthy People 2010, and the low vaccination rate reported by the USRDS. This project
increased the number of ESRD patients that received the influenza vaccination by 14%. During
the 2007-2008 influenza season 65.4% of patients received the vaccine. The interventions of this
project resulted in an increased rate of vaccination in the 2008-2009 influenza season to 79.4%.
This project was continued for the 2009-2010 flu season and resulted in 81.2% of patients
receiving the flu vaccine. This was an improvement of 1.8%. For the flu season 2010-2011, our
Quality Improvement Work Plan
Task 1.c Influenza Vaccination
goal was to improve the vaccination rate by 2%. The Network exceeded the goal and achieved a
vaccination rate of 83.5%, which was a 2.3% increase. For CY 2011-2012, the Network will
focus on maintaining the current influenza vaccination rate of 83.5% by reducing the number of
refusals of dialysis patients.
Goal
Measure
Methodology
For CY 2011-2012, Network 2 will maintain their baseline influenza vaccination rate of 83.5%
by the end of the project.
Baseline measure: influenza vaccination rates identified by utilizing a scan of a random sample
of prevalent patients in Network 2 facilities from 2010-2011.
Numerator: Total number of prevalent patients who received influenza vaccination in the
random sample.
Denominator: Total number of prevalent patients in random sample that were returned.
Baseline: 83.5%.
Environmental Scan
1. Utilize environmental scan developed for the influenza vaccination project in 2008.
2. Determine the number of patients needed in the random sample to be statistically significant
o The influenza immunization rate in Network 2 for flu season 2010-2011 was
83.5%.
o To have an 80% chance of detecting an increase of 0% of immunization rate at
the statistical significance level of 0.05, 930 patients are required for the random
sample.
o To account for 20% of non-responses, we will recruit at least 1116 patients for
the random sample.
3. Select the random sample from the SIMs database.
o Patients must be in the facility the entire flu season – September to March
o Include pediatric and adults patients who are receiving hemodialysis or
peritoneal dialysis.
o Excluded from the sample are transplant patients and patients receiving
treatment by the Veteran Administration.
4. Send out re-measure environmental scan to facilities that have patients in the random
sample.
o The scan should be answered based on the 2011-2012 flu season.
o Request return of environmental scan to Network within 3 weeks from mail
date.
o To facilitate return 2 fax reminders will be sent out – 1 several days prior to the
due date and the other 1 on the due date.
o The quality improvement data coordinator will call facilities that have not
returned the scan.
5. Analyze and review results of environmental scan with the Medical Review Board. Identify if
goal has been met.
Education
1. Patient
o Article in PAC Notes – focus reasons to get the influenza vaccine
o Presentation at regional PAC meetings and PAC chair meetings
o Provision of new patient information developed by Centers for Disease Control
and Prevention and/or Immunization Action Coalition and sent to the providers
for distribution.
2. Professionals
Quality Improvement Work Plan
Task 1.c Influenza Vaccination
o Reminders will be sent out, via email and/or fax before flu season to order flu
vaccines for facility.
o Article in Network Notes
o Distribution of current and relative information to nephrologists, nurse
managers and administrators.
o Immunization package will be developed and sent to facilities with resources,
factsheets, mostly from CDC to help assist with educational days.
o Post to Network’s web site “Vaccination Tool Kit” developed by the Forum
ESRD Medical Advisory Committee. Notify facilities by email and fax that this
is available.
Targeted facilities
1. Providers from CY 2010-2011 flu season with facilities who had <70% of patients
vaccinated for influenza.
2. Request will be sent to the targeted facilities to submit a quality improvement plan for
immunizations.
3. Targeted providers will be asked to pick a day and date for immunization educational days
for the months of October, November, December and January. There will be 4 topics:
General Immunization Information, Prevention of Influenza/Pneumonia, Myths and Facts
about Immunization, and Complications/statistics. Each month the facility will be asked to
choose one of the four educational topic to present
4. Immunization package will be developed and sent to facilities with resources, factsheets,
mostly from CDC to help assist with educational days.
Tracking – Facility staff are encouraged by the Network to have > 90% of their patients receive
immunizations for influenza. In previous years the Network has focused on understanding the
reasoning behind why patients refuse immunizations. This would give the Network an
understanding of the needs of the providers and provide them with educational resources and
support. This year the Network will focus on understanding the provider’s practices regarding
patients who refuse vaccinations. A tracking tool will be developed to help facilities track
influenza vaccination.
1. Tracking tool includes a worksheet to list all the patients in a specific facility and whether or
not they received the influenza vaccination. This information is then totaled on a summary
sheet with patient census and the percentage of patient’s who have been vaccinated for
influenza. In addition, part one of the summary sheet, will ask for the percentage rate of
initial refusals, in addition to multiple refusals. This information is needed to determine if
the refusal rate is decreasing each month. The summary sheet is sent to the Network on a
monthly basis. If a facility achieves a 90% goal they then will track and send the information
to the Network on a quarterly basis until the end of the project in April 2012.
2. Part II of the summary sheet, will ask a few questions about the facilities practice patterns
and education at the time a patient refuses the vaccine. This will provide the Network with
an educational focus and to develop ideas for facilities to overcome barriers to this process
and improve patient adherence.
3. Facilities will track patients monthly and the summary sheet sent to the Network until the
facility achieves the Healthy People 2020 target of 90% of their patients vaccinated for
influenza. In addition, the targeted providers will continue to provide a day and date of their
monthly “immunization education day”. If a facility achieves 90% of their patients
vaccinated prior to December 2011, then that facility will track their patients on a quarterly
basis until the end of the project April 2012.
Quality Improvement Work Plan
Task 1.c Influenza Vaccination
Re-Measure
Timeline
4. At the end of the project April 2012, the facilities who vaccinated > 90% of patients will
receive a certificate of achievement from the Network.
Influenza vaccination rates identified by utilizing a scan of a random sample of statistically
significant prevalent patients in Network 2 facilities from 2011-2012 flu season.
Numerator: Total number of prevalent patients who received influenza vaccination in the
random sample.
Denominator: Total number of prevalent patients in random sample that were returned.
Improvement = re-measure – measure.
Environmental Scan
1. Determine the number of patients needed in the random sample – July 2011
2. Select the random sample from the SIMs database –March 2012.
3. Send out re-measure environmental scan to facilities –March 2012
4. Analyze and review results of environmental scan –April 2012.
Education
Patient
1. Article in PAC Notes –September 2011
2. Presentation at regional PAC meetings and PAC chair meetings – monthly meetings
3. Provision of new patient information –September 2011 and when available
Professionals
1. Post to Network’s web site “Vaccination Tool Kit” developed by the Forum ESRD Medical
Advisory Committee – July 2011
2. Notify facilities to order vaccines – July 2011
3. Request a QIP from targeted providers who had an influenza rate below 70% CY 20102011 - August 2011
4. Request Educational Days from targeted providers for the Months of October, November,
December and January. –August 2011
5. Send out resources from the vaccination toolkit to those facilities writing a QIP. August
2011
6. Distribution of current and relative information to nephrologists, nurse managers and
administrators – focused on the four educational topics.- September 2011
Tracking
1. Update tracking tool for Influenza –July 2011
2. Send tracking tool to providers September 2011 and monthly thereafter. If > 90 of patients
are vaccinated prior to December 2011, the facility will be required to update their tracking
quarterly. By April 2012, if facility has continued to achieve a vaccination rate above 90%,
facility will receive a certificate of achievement.
3. Request each month from targeted providers a monthly “immunization educational day” out
of the choice of educational topics starting in October and ending in January 2012.
Project
Reports
Report to CMS via Quarterly Progress and Status Report, and MRB and BOD meetings
Quality Improvement Work Plan
Task 1.c Pneumonia Vaccination
Project Lead
Chris Scalamandre, RD, CDN, Quality Improvement Coordinator
Project
Description
Pneumonia can lead to serious complications and death in the dialysis population. The Network
urges dialysis facilities to track and vaccinate patients against pneumonia.
For CY 2011-2012, the Network will increase the number of patients who receive the
pneumonia vaccine from baseline by 5%. The project will include developing an environmental
scan to determine baseline data. The Network will provide a tracking form for facilities to
determine which patients have received the pneumonia vaccine and who needs to be vaccinated.
Aggregate data from the tracking form from the facilities will be asked to be sent to the
Network. Educational resources will be provided to facilities for patients and staff.
Background
Serious illnesses are caused by pneumoccocci such as bacteremia, meningitis and
pneumonia. Each year in the United States, there are an estimated 175,000 hospitalized
cases of pneumococcal pneumonia, 34,500 cases of bacteremia and 2,200 cases of
meningitis. Invasive disease (bacteremia and meningitis) are responsible for the highest
rates of death among the elderly, patients who have underlying medical conditions and
children under age 2. Data from community-based studies indicate that overall annual
incidence of pneumococcal bacteremia in the United States is an estimated 15-30 cases
per 100,000; the rate is higher for persons aged greater than or equal to 65 years (50-83
cases per 100,000 population) and for children aged less than or equal to 2 years (160
cases per 100,000 population)
The rate of pneumococcal pneumonia vaccinations has grown from 16 percent in 2003-2004 to
22 percent in 2007-2008. This rate remains relatively low compared to the 2008 influenza rate of
62.4%. Although, both remain below the Healthy People 2020 target of 90%. Dialysis patients
have 14-16 times higher pulmonary infectious (pneumonia) mortality rates compared with the
general population. The relative risk for death at 6 months of the first-year for dialysis patients
who experienced an episode of pneumonia was 5.1.Also the relative risk for cardiovascular
events in the first 6 months also was greater at 3.02.
On April 15, 2008 the final rule for the Conditions for Coverage (CfC) for ESRD Facilities was
published. In the CfC it states that the patient assessment must include an immunization
history and the quality assessment and performance improvement program must develop
recommendations and action plans to promote immunizations. The influenza vaccination
project was selected by the MRB in CY 2008 to support the requirements of the CfC, the goal
of the Healthy People 2010, and the low vaccination rate reported by the USRDS. Since the
baseline rate of 65.4% at the start of the Influenza project in 2008, the Network has improved
the influenza vaccination rate by 18.1%. In CY 2010-2011 the influenza vaccination rate reached
a maximum rate of 83.5%.
Since the Network has had great success with the influenza immunization project, the MRB has
decided this year to continue with a Network project focusing on improving immunizations in
dialysis patients. The Network will continue to support the CDC requirements of the Healthy
People 2020 goal to improve immunization rates in a high risk population to 90% for both
pneumonia and influenza. The Network will concentrate on maintaining their influenza rate of
83.5%, while improving the pneumonia rate by 5 % from baseline.
Quality Improvement Work Plan
Task 1.c Pneumonia Vaccination
Goal
Measure
Methodology
To increase the number of patients vaccinated with the pneumonia vaccine and improve the
pneumonia vaccination rate by 5% in Network 2.
Baseline measure: pneumonia vaccination rates identified by utilizing a scan of a random sample
of prevalent patients in Network 2 facilities as of August 2011.
Numerator: Total number of prevalent patients who received pneumonia vaccination in the
random sample.
Denominator: Total number of prevalent patients in random sample that were returned.
Baseline: N/A
Environmental Scan
1. Develop environmental scan similar to the influenza scan developed for the influenza
vaccination project in 2008.
o Facility questions will include:
 Written protocols for tracking vaccinations given and for
administering vaccinations
 How the facility tracks vaccinations given
 Is the facility administering vaccinations to patients
 If the facility requires an MD order to give a vaccination.
o The random sample of facility patients will request information on whether or
not the patient ever received a pneumonia vaccine, and if so, how long ago was
it.
2. Determine the number of patients needed in the random sample to be statistically significant
o Assumption that the pneumonia immunization rate in Network 2 is similar to
the current ESRD national average- 22%.
o To have an 80% chance of detecting an increase of 5% of immunization rate at
the statistical significance level of 0.05, 930 patients are required for the random
sample.
o To account for 20% of non-responses, we will recruit at least 1116 patients for
the random sample.
3. Select the random sample from the SIMs database.
o Patients must be in the facility from September to March
o Include pediatric and adults patients who are receiving hemodialysis or
peritoneal dialysis.
o Excluded from the sample are transplant patients and patients receiving
treatment by the Veteran Administration.
4. Send out baseline environmental scan to facilities that have patients in the random sample.
o Request return of environmental scan to Network within 3 weeks from mail
date.
o To facilitate two fax reminders will be sent out- 1 several days prior to the due
date and the other 1 week after the due date.
o The quality improvement coordinator will call facilities that have not returned
the scan.
5. Analyze and review results of environmental scan with the Medical Review Board.
o Determine if the number of patients in the random sample needs to be adjusted
based on number of patients that have received pneumonia vaccinations.
o Identify the re-measure goal based on goal of a 5% improvement in
immunizations.
6. Select random sample for re-measure based on criteria above. Send out re-measure
Quality Improvement Work Plan
Task 1.c Pneumonia Vaccination
environmental scan to facilities that have patients in the random sample.
o Request return of environmental scan to Network within 3 weeks from mail
date.
o To facilitate return 2 fax reminders will be sent out – 1 several days prior to the
due date and the other 1 on the due date.
o The quality improvement data coordinator will call facilities that have not
returned the scan.
7. Analyze and review results of environmental scan with the Medical Review Board. Identify if
goal has been met.
Education
1. Patient
o Article in PAC Notes – focus on the importance of receiving the peumovax vaccine
o Presentation at regional PAC meetings and PAC chair meetings
o Provision of new patient information developed by Centers for Disease Control and
Prevention and/or Immunization Action Coalition and sent to the providers for
distribution.
2. Professionals
o Reminders will be sent out, via email and/or fax before pneumonia season to order
vaccines for facility
o Article in Network Notes
o Distribution of current and relative information to nephrologists, nurse managers
and administrators.
o Immunization package will be developed and sent to facilities with resources,
factsheets, mostly from CDC to help assist with educational days.
o Post to Network’s web site “Vaccination Tool Kit” developed by the Forum ESRD
Medical Advisory Committee. Notify facilities by email and fax that this is available.
Targeted facilities
1. Providers from CY 2010-2011 flu season with facilities who had <70% of patients
vaccinated for influenza.
2. Request will be sent to the targeted facilities to submit a quality improvement plan for
immunizations.
3. Targeted providers will be asked to pick a day and date for immunization educational days
for the months of October, November, December and January. There will be 4 topics:
General Immunization Information, Prevention of Influenza/Pneumonia, Myths and Facts
about Immunization, and Complications/statistics. Each month the facility will be asked to
choose one of the four educational topic to present
4. Immunization package will be developed and sent to facilities with resources, factsheets,
mostly from CDC to help assist with educational days.
Tracking Facility staff is encouraged by the Network to have > 90% of their patients receive
immunizations for pneumonia. In previous years the Network has focused on understanding the
reasoning behind why patients refuse immunizations. This would give the Network an
understanding of the needs of the providers and provide them with educational resources and
support. This year the Network will focus on understanding the provider’s practices regarding
patients who refuse vaccinations. A tracking tool will be developed to help facilities track the
pneumonia vaccination.
Quality Improvement Work Plan
Task 1.c Pneumonia Vaccination
Re-Measure
Timeline
1. Tracking tool includes a worksheet to list all the patients in a specific facility and whether or
not they received a pneumonia vaccination. This information is then totaled on a summary
sheet with patient census and the percentage of patient’s who have been vaccinated for
pneumonia. In addition, part one of the summary sheet, will ask for the percentage rate of
initial refusals, in addition to multiple refusals. This information is needed to determine if
the refusal rate is decreasing each month. The summary sheet is sent to the Network on a
monthly basis.
2. Part II of the summary sheet, will ask a few questions about the facilities practice patterns
and education at the time a patient refuses the vaccine. This will provide the Network with
an educational focus and to develop ideas for facilities to overcome barriers to this process
and improve patient adherence.
3. Facilities will track patients monthly and the summary sheet sent to the Network until the
facility achieves the Healthy People 2020 target of 90% of their patients vaccinated for
pneumonia. In addition, the targeted providers will continue to provide a day and date of
their monthly “immunization education day”. If a facility achieves 90% of their patients
vaccinated prior to December 2011, then that facility will track their patients on a quarterly
basis until the end of the project April 2012.
4. At the end of the project April 2012, the facilities who vaccinated > 90% of patients will
receive a certificate of achievement from the Network.
Pneumonia vaccination rates identified by utilizing a scan of a random sample of statistically
significant prevalent patients in Network 2 facilities from 2011-2012 flu season.
Numerator: Total number of prevalent patients who received pneumonia vaccination in the
random sample.
Denominator: Total number of prevalent patients in random sample that were returned.
Improvement = re-measure – measure.
Environmental Scan
1. Determine the number of patients needed in the random sample – July 2011
2. Select the random sample from the SIMs database – September 2011 for baseline; March
2012 for re-measure.
3. Send out baseline environmental scan – September 2011
4. Send out re-measure environmental scan to facilities –March 2012
5. Analyze and review results of environmental scan – October 2011; April 2012.
Education
Patient
1. Article in PAC Notes on immunizations including pneumonia–September 2011
2. Presentation at regional PAC meetings and PAC chair meetings – monthly meetings
3. Provision of new patient information –September 2011 and when available
Professionals
1. Post to Network’s web site “Vaccination Tool Kit” developed by the Forum ESRD Medical
Advisory Committee – July 2011
2. Notify facilities to order vaccines – July 2011
3. Request a QIP from targeted providers who had an influenza rate below 70% CY 20102011 - August 2011
4. Request Educational Days from targeted providers for the Months of October, November,
December and January. –August 2011
5. Send out resources from the vaccination toolkit to those facilities writing a QIP. August
2011
6. Distribution of current and relative information to nephrologists, nurse managers and
Quality Improvement Work Plan
Task 1.c Pneumonia Vaccination
administrators – focused on the four educational topics. September 2011
Tracking
1. Update tracking tool for pneumonia –July 2011
2. Send tracking tool to providers September 2011 and monthly thereafter. If > 90% of
patients are vaccinated prior to December 2011, the facility will be required to update their
tracking quarterly. By April 2012, if facility continues to achieve a vaccination rate above
90%, facility will receive a certificate of achievement.
3. Request each month from targeted providers a monthly “immunization educational day” out
of the choice of educational topics starting in October and ending in January 2012.
Project
Reports
Report to CMS via Quarterly Progress and Status Report, and MRB and BOD meetings