The
Childhood/Adolescent Immunization Program
Colorado Region
Introduction
The Childhood and Adolescent Immunization Program was developed for
the Kaiser Permanente Colorado (KPCO) Denver/Boulder Local Market in
response to our commitment to our prevention program and improving the
health status of the children and adolescents. Team Members are listed
in Table
1.
Background
In 1996, the combination of new vaccines and new data, which changed
the ages at which vaccines are known to be efficacious, made it necessary
to revise our immunization schedules. The result of these changes was
a decline in our overall immunization rates for two-year-old infants
from 1995 through 1996 as measured by the HEDIS (Health-Plan Employer
Data and Information Set). Further, effectively communicating and coordinating
new schedules and vaccines to our providers and staff proved to be a
formidable challenge.
Process
In late 1996, a small group of staff and providers reviewed the records
of all delinquent children in our HEDIS subset. In this process, we
identified several opportunities for improvement. Among our discoveries,
we found that a significant percentage of delinquencies occurred because
of missed opportunities and providers following outdated schedules or
incorrect "relative" contraindications. Problems with information
and communication were identified. These problem areas became the focus
of our new initiatives. These discoveries challenged all of us to achieve
a higher level of quality improvement, and our team quickly embraced
the new immunization initiatives.
Objectives
The objective of our project was to improve the immunization rates of
our children and to assure that these children were immunized accurately
and on schedule. The foundation of our enhanced program was formal adoption
of the Centers for Disease Control and Prevention (CDC) Standards
for Pediatric Immunization Practices.1 As a result, we
initiated an aggressive population-based immunization campaign that
included tracking and outreach to every delinquent child aged 14 months,
20 months, and 12.5 years within our KP Region. Our 1998 regional
performance goal was to achieve the top quartile for all HEDIS quality
measures.
Methodology
Scope
Kaiser Permanente operates 15 medical offices in the Denver/Boulder
Local Market, and more than 145 providers within our organization are
involved with caring for children. Our Immunization Program within KPCO
targets our entire population of children, not just the HEDIS subset.
Although most of our work has been with infants and toddlers aged 0
to two years, the focus on achieving higher coverage rates for all
children has greatly intensified because of this initiative. Our Departments
of Pediatrics, Family Practice, and Prevention jointly developed an
implementation plan for this new effort. Molly Burchell, MD, Chief of
Pediatrics, led the project and currently champions the Immunization
Program. The local health care team champions, who perform all the detailed
outreach to members, are critical to improvements. The champions are
MAs, LPNs, RNs, or nursing supervisors, in cooperation with physicians,
depending on the interests and skills of the team.
Quality
Measures
The primary measure of the success of the interventions is improved
immunization coverage rates. If our interventions are working, we should
see a decrease in variation and improved rates both at individual medical
offices and as a program. As a regional quality assurance priority,
the Primary Care Quality Council reviews all HEDIS quality measures,
including childhood immunization rates. We created a clear channel of
communication and accountability by integrating our efforts with our
Primary Care Quality Council. Feedback and new ideas are collated to
develop improved processes that are adopted, along with our best practices,
across our KP Region. Childhood immunization coverage rates are critical
HEDIS quality indicators for our KP Regional as well as the national
KP Program. This initiative and the striking results coincide with our
focus on HEDIS measures as a foundation of our quality program.
Process
Implementation
In 1997, we formally adopted the Standards for Pediatric Immunization
Practices as recommended by the CDC and used this as a template
for our improvement plan. In our review of existing practices, we identified
four critical areas as opportunity for improvement. These four areas
represented improvement opportunities in six of the CDC standards.
1.
Assess immunization status at every encounter, and follow only true
contraindications (CDC Standards 4 and 7). We implemented printing
of the immunization record throughout our KP Region from our computerized
immunization tracking system for every child at all primary care, urgent
care, and trauma visits, including weekend care visits. This strategy
further helped us capture missed opportunities, which has been identified
nationally as one of the greatest barriers to achieving high immunization
rates. True contraindications versus relative contraindications were
discussed at department meetings and communicated by phone, memoranda,
and posters distributed by the Colorado Department of Public Health
and Environment2 in medication rooms throughout our KP Region.
- Standard
4–"Providers utilize all clinical encounters to screen and,
when indicated, immunize children."
- Standard
7–"Providers follow only true contraindications."
2.
Operate a tracking system and audit to assess immunization coverage
levels (CDC Standards 12 and 14). In early 1997, we used a computerized
tracking system as the formal chart record for child immunizations.
We had minimal tracking of delinquent children and no clear goals for
capturing under-immunized children. We focused our efforts on tracking
14-month and 20-month-old children. We distributed monthly lists of
all delinquent children to provider/nurse teams and created expectations
for return of these lists six weeks after distribution. Teams were expected
to contact these patients and to persist until the child's status was
brought up to date. If this update was not possible, the reasons were
documented. The immunization team reviewed the audits and provided direct
feedback to providers and health care teams. This process generated
numerous educational opportunities and requests for training on immunization
practices. This process also helped our Regional team learn where information
was most lacking, thus enabling us to focus our educational efforts
in these areas.
- Standard
12–"Providers operate a tracking system."
- Standard
14–"Providers conduct semiannual audits to assess immunization
coverage levels and to review immunization records in the patient
populations they serve."
3. Maintain
up-to-date, easily retrievable medical protocols in examination rooms
and offices at all our Regional locations (CDC Standard 15). The
size and configuration of our system posed considerable communication
challenges with regard to immunization schedule changes. In the process
of trying to implement Standard 15, we developed the Immunization
Tool Kit,3 a user-friendly manual designed to provide
current, accurate information and recommendations for immunization of
children. The manual also serves as a reference for materials from the
Advisory Committee on Immunization Practices (ACIP) and from the CDC
and provides other critical information such as Vaccine Information
Sheets and Adverse Events Reporting forms (AVERS). Posting the current
immunization schedule in each examination room used for children is
now a part of our primary care quality assurance measures. Finally,
the system provides a process for the replacement of outdated schedules
and vaccine information, which allows us to keep current with practices
and protocols. The Immunization Tool Kit received rave reviews
from staff and providers and continues to be used widely on a daily
basis.
- Standard
15 – "Providers maintain up-to-date, easily retrievable
medical protocols at all locations where vaccines are administered."
4. Provide
ongoing education to staff and physicians (CDC Standard 18). Specifically
targeted education and training was delivered to local facility teams
and to large departments. In addition, specific feedback was given to
individual providers when schedules were not followed or when relative
contraindications were used instead of true contraindications. Through
the above tracking and auditing process, we were able to identify local
areas of concern (providers not following the proper schedule) as well
as regional problems (eg, low Varivax compliance). We customized local
team education and feedback to the specific need while directing our
KP Regional interdepartmental education programs to the more global
problem areas.
- Standard
18 –"Providers receive ongoing education and training on
current immunization recommendations."
Quantitative
Analysis
Statistical analysis does not apply to this project.
Results
The result of these initiatives has been not only the reversal of a
declining trend but the achievement of our highest rate ever for diphtheria-tetanus-pertussis
(DTP), polio, HIB, and hepatitis B vaccinations. In fact, for childhood
immunization rates, we surpassed our previous target and are in the
top decile of all KP Regions.
Comment
The Healthy People 20004 national goal is to assure that
90% of our children are fully immunized. Our results support the evidence
that when the CDC's Standards for Immunization Practice are implemented
fully, such high coverage rates can be achieved. The objective to improve
our immunization rates was achieved by combining tools, skills, and
education with accountability to our Primary Care Quality Council.
This immunization
program with intensive tracking and outreach, coupled with our Immunization
Tool Kit as a vehicle for quality processes and communication, has
been shared widely across the country. We have given Immunization
Tool Kits and discussed the program with the KP Northwest, Hawaii,
Kansas City, and Colorado Springs Regions. The staff emphasizes the
user-friendly, hands-on format of the Tool Kit as a manual used daily
in the clinical setting. We have also shared materials with many organizations
outside KP. This proactive population-based program exemplifies the
goals and values throughout KP, and its "health state management"
process can be transferred and adopted in many venues as "disease
state management" for our population. The project truly required
a multidisciplinary approach because it was critical to have the physician/provider
knowledge and expertise as well as diligent, detailed implementation
by the nursing staff.
Conclusion
In conclusion, even as vaccine technology continues to expand, we have
a system in place to immunize our children efficiently and accurately
despite advances and increasing complexity of the technology. Our quality
improvement process of measuring, analyzing the data, formulating an
improvement plan, implementing, and remeasuring can be generalized to
any such problem. Any dedicated team with time, energy, and a clear,
specific goal can be successful. The success of the Childhood/Adolescent
Immunization Program has been possible only through true ownership and
commitment at all levels of the organization and passion for the care
of children.
References
1. National Immunization Program, Centers for Disease Control and Prevention.
Standards for Pediatric Immunization Practices. Atlanta, GA: Center
for Disease Control and Prevention; February 1996; Seventh Printing.
2. Colorado State Department of Public Health and Environment. Guide
to Contraindication in Childhood Vaccination. April 1996.
3. Burchell MF, Sharp EA. Kaiser Permanente Medical Care Program. Immunization
Tool Kit. Denver, CO: Kaiser Permanente Medical Care Program, Colorado
Region; September 1999 [available from the authors].
4. National Center for Health Statistics. Healthy People 2000 review,
1998-99. Hyattsville, MD: US Public Health Service; 1999.
