Becker's Hospital Review

35 Executive Briefing Make the CASE for vaccination The IHI's PDSA model consists of 2 parts: 3 fundamental questions and the PDSA cycle. The fundamental questions ask the initiators of a potential solution to identify 1) what they hope to accomplish, 2) how they will know that observed change is actually an improvement, and 3) what specific change will result in concrete improvement. After testing a change on a small scale, learning from each test, and refining the change through several PDSA cycles, the change may be implemented on a broader scale. Gundersen implemented 5 specific PDSA changes involving both EHR and provider education to facilitate improvements in vaccination coverage among children and adolescents 11-18 years of age: 1. Create electronic alerts and reminders to notify clinicians when a patient is due or overdue for a vaccine. 2. Create a centralized process for electronic alerts and reminders. 3. Electronically schedule follow-up vaccine doses to eliminate missed vaccination opportunities. 4. Conduct system-wide provider education on addressing vaccination misperceptions among parents and patients. 5. Create real-time prompts in the EHR with educational information for providers to share during patient visits. For the provider education component, Dr. Naik assembled a small team of clinicians, which included 3 pediatricians and 1 family medicine physician, to travel to different care sites in the area served by Gundersen Health System. These physicians trained their fellow providers to address vaccine hesitancy by using the CASE methodology: • Corroborate: Acknowledge parental concern and find points of agreement to set the tone for a respectful conversation. • About me: Describe what efforts you have made to improve your knowledge and expertise on the issue. • Science: Describe what the science says regarding the importance of vaccination and any vaccination concerns. • Explain/Advise: Give the patient science-based advice. The educational sessions were well-received by Gundersen staff, according to Dr. Naik. The sessions also allowed the team to address another hindrance to vaccination — clinician hesitancy. Other studies have corroborated Dr. Naik's findings. In a review of 185 previously published studies examining healthcare provider vaccine hesitancy, researchers found providers often had limited resources and inadequate information to address patients' vaccine concerns. This lack of resources can inhibit a provider's inclination to recommend vaccination. Several studies also found that healthcare providers who were vaccinated themselves (or who intended to be vaccinated) were more likely to recommend vaccination to their patients. According to Dr. Naik, "The single factor that's most important in whether or not a family accepts a vaccine has to do with the strength of the provider recommendation." The effort at Gundersen yielded improvements in adolescent vaccine coverage. For one adolescent vaccine, the health system increased vaccination rates among its male pediatric patient population from 30.9 percent in 2015 to 55.4 percent by the end of 2017, a rate that is substantially higher than the 31.4 percent national average. The Gundersen roadmap During the implementation of the initiative, Dr. Naik and colleagues identified potential hindrances to the program and devised strategies to address them. For example, the vaccine champion team found hands-on training was necessary for members of staff beyond frontline providers. The Gundersen team also discovered that continuous analysis of vaccination data and the identification of new opportunities within the EHR to enhance and sustain documented improvements were essential components of the program's success. Dr. Naik said Gundersen's culture, which places an emphasis on launching initiatives designed to improve the well-being of its patients and community, specifically contributed to the program's success. However, he noted that the program was designed to be replicable and other health systems can follow the Gundersen "roadmap." Dr. Naik also cautioned that culture alone is not enough to ensure significant improvements. For other organizations to "truly move the needle" on vaccine acceptance, they must implement quality improvement methodologies and identify provider vaccine champions internally. Once champions are identified, individuals tasked with leading the initiative need to monitor the implementation of the initiative and make a conscious effort to learn what works and what falls short. For its part, Gundersen is happy to spread the word. Dr. Naik has shared information on his organization's program in a number of venues. Additionally, other hospitals and health systems can access the Gundersen clinical program through Epic EHR. "The work that we've done from a health information technology standpoint has been turned into a clinical program," Dr. Naik said. "It's certainly possible for other organizations to have similar success." n For more than a century, Merck has been inventing for life, bringing forward medicines and vaccines for many of the world's most challenging diseases. Today, Merck continues be at the forefront of research to deliver innovative health solutions and advance the prevention and treatment of diseases that threaten people and animals around the world.

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