Making Your Clinic a Lean, Mean, Vaccinating Machine
Alone we can do so little; together we can do so much.
We, as clinicians, can do everything right. We can educate ourselves regarding the science behind vaccines, we can use every encounter to offer vaccines, and we can encourage patients to voice their questions and concerns so that they know we are open to honest discussion about vaccines. But, what if we can’t even get the patients to come into the office? What if the patient is there, but in the process of rooming, the medical assistant says, “Gosh, I waited to get my child vaccinated for HPV. I didn’t want my daughter thinking she could start having sex right away.” (You may wonder if this truly ever happens, but unfortunately it does). What if you have the patient in the room, they are ready to have the vaccine, and it turns out the clinic ran out of the vaccine a week ago. I can’t tell you how frustrating it is to spend time and energy convincing a vaccine-hesitant patient to get a vaccine, only to not have the vaccine available to give! We’re forced to send them out the door to return later. What are the chances that that person is going to come back?
Not only do we need to educate ourselves about vaccine science and fact, we need to educate our staff, those who are on the frontlines speaking with patients more often than we do. We also need to create organizational efficiencies that will bring patients into the clinic, will convey a strong and consistent message about the importance of vaccines, will facilitate the follow-up necessary for vaccine series so patients’ care doesn’t fall through the cracks, and will make sure we have the tools and supplies we need to do our jobs effectively.
This chapter provides a list of organizational interventions that will help you increase your success rates in getting your patients vaccinated and help take some of the pressure off of you as the only person responsible for success or failure of your clinic’s vaccine program.
1. Participate in your community’s vaccine registry and encourage other medical providers and pharmacies to participate as well. These state-run Immunization Information Systems (IIS) are “confidential, population-based, computerized databases that record all immunization doses administered by participating providers to persons residing within a given geopolitical area.”1 At an individual level, the IIS help us to keep patients on schedule with vaccines and decrease
the chances that they will get unnecessary repeat doses. At the population level, they can be used for surveillance and in guiding public health initiatives. Your regional public health department can put you in touch with your local IIS so that you can become enrolled as a participating provider (Box 14.1).
2. Get your clinic involved in the Vaccines for Children (VFC) program. The VFC program is a “federally funded program that provides vaccines at no cost to children who might not otherwise be vaccinated because of inability to pay.” This includes children younger than 19 years of age who are Medicaid-eligible, Alaskan Native, American Indian, uninsured, or underinsured.2 The VFC program allows you to provide government-purchased vaccines for your eligible patient population with reduced out-of-pocket costs for you, thus increasing vaccination rates and decreasing burden of disease in this at-risk population. To become involved, you will need to contact your state VFC program coordinator and ask for a Provider Enrollment Package to be mailed out. When this is completed, you will need to prepare for a site visit to go over the administrative requirements of the program and to ensure proper storage and handling of the VFC vaccines (Box 14.2). Then, let the vaccinating begin!
3. Get the patients in the door. Use mailings, use robocalls, or use health coaches or medical assistants to make vaccine stats a “vital sign,” something we review on every patient at every encounter (office visit, telephone call, etc.). Thinking about vaccines needs to become second nature for us and for our medical assistants. In looking at our vaccination successes and where we have room for improvement at the local level, it seems we sometimes miss out on getting our preteens and teens in for their well-child checks. Our percentages for getting kids up-to-date on their Tdap, meningitis, and HPV vaccines, as a result, are not where they should be. In 2017, the national average for adolescent vaccine coverage was best for Tdap at 88.7%, MenACWY coverage for one dose was 85.1% but only 44.3% for both recommended doses, and HPV coverage was 65.5% for one dose and a mere 48.6% for completion of the series.3 We all know how life gets in the way of doing things to take care of ourselves. Sometimes we need a gentle nudge or reminder. Perhaps we could query our patient databases
on a monthly basis and send out “Happy Birthday” cards to all of our kids turning 11, reminding them to return to clinic for their wellness visit and to get caught up on these very important vaccines. This is just one idea. There is no one specific way to tackle this effort. Each clinic or health system may have their own unique approaches to making this work. But we do need to put our heads together to make sure that patients are getting in. We can’t vaccinate them if they are not in front of us.
4. Educate your staff—everyone from the front office to schedulers to medical assistants to your fellow providers. Everyone needs to know the facts and the recommendations about vaccines so that we can all be offering the same message. Nothing is more confusing to patients than having one person tell them one thing and someone else giving conflicting advice. We need to be on the same page. This approach helps to address any vaccine hesitancy in your staff, as well. There are always staff who initially refuse to get their annual flu vaccine, but with a bit of education, and a requirement to wear a mask for the entirety of the flu season if they continue to opt against vaccination, we can often get staff to change their minds. At the end of the book, you will find educational resources for patients and staff. You can use these to create a talk for your clinic. Schedule a morning or lunchtime meeting and go over immunization recommendations and facts about vaccines with your staff. Give them talking points that they can use when working with patients. Moreover, set universal expectations for review of patients’ vaccine histories (for example, when patients call in for refills on medications, have the medical assistants check to see if they are up-to-date and bring them in if they are due). In my clinic, we have handed out information about vaccines that addresses commonly voiced concerns (see Appendix B: Fast Facts about Vaccines for Patients and Clinic Staff) and have given each staff member a button to wear stating our commitment to vaccinating. We also hold a drawing where staff put responses to vaccine questions (For example, “True or False: The flu shot protects against the stomach flu”) in a box and, once a week, we draw a winner for a Starbucks gift card. Again, use your creativity developing your own ideas. Let’s try to make vaccine education fun and engaging!
5. Use standing orders for vaccines.4 If we train our staff well and we trust and expect that they will follow the proper guidelines for giving vaccines, we can allow them to give vaccines per protocol without us having to sign off on every single shot. We can review the protocols and sign off once. This suffices for “giving an order” for vaccines and takes up less of our time having to enter individual orders or sign off on each vaccine (Box 14.3). This allows our staff to work to the limits of their training and demonstrates our trust in them to provide quality care for our patients. When staff are involved directly with patient care, they feel more a part of the team. Vaccination rates go up and staff engagement improves. It is a win-win situation.