The power of persuasion takes you only so far

Hospital turns to mandate for higher rate

If the goal is universal influenza vaccination, the answer is mandatory vaccination.

That was the conclusion at Dartmouth-Hitchcock Medical Center in Lebanon, NH, where about 75% of employees voluntarily received the influenza vaccine. That seemed to be a plateau, and efforts to further expand coverage of the vaccine weren't successful, says Robert McLellan, MD, MPH, chief of Occupational and Environmental Medicine.

The hospital used the usual strategies, providing lots of reminders and education about influenza and the vaccine, offering it on all shifts, making it as convenient as possible. Meanwhile, the patient representative on the hospital's quality committee was insistent that all health care workers should be vaccinated, says McLellan.

"Wouldn't you want your health care worker to do everything possible to reduce the risk of transmitting the flu?" he asked committee members.

So the hospital took a new tack. There was a new goal for influenza immunization of 90%. "If we didn't reach that goal there might be a need to have a more stringent policy," McLellan says employees were told.

Meanwhile, the hospital also added an incentive. Anyone who had the vaccine would receive a one-time $50 discount on their health insurance premium — essentially a tax-free $50. "We didn't require proof [for the incentive]," he says. "At the time of benefit enrollment, we asked on the honor system to attest you either have or will get the flu shot."

"Somewhat to our surprise, it really didn't do anything," he says. The vaccination rate stayed at about 75%.

The hospital's leadership decided that persuasion alone wasn't going to push the rate higher. This fall, for the first time, Dartmouth-Hitchcock is implementing a mandatory vaccination policy. Exemptions are provided for people with medical contraindications or "sincere religious beliefs," although people with exemptions must wear a surgical mask during patient contact. The policy includes contract employees and students.

"It's critical that it be understood that this is not an employee health policy, it is an institution policy driven by a concern for patient safety," McLellan says. "Employee health is not responsible for any of the enforcement or disciplinary action associated with this. Employee health is simply executing a policy the institution has enacted."

McLellan is past president of the American College of Occupational and Environmental Medicine, which has a position statement supporting influenza immunization but not mandatory policies, which is says are unnecessarily punitive.

Dartmouth-Hitchcock simply decided that it couldn't reach its influenza immunization goals without a mandatory policy, he says. And while there's been some pushback from employees, others have praised the decision, he says.

"I think there's little doubt that the flu vaccine is safe and effective," says McLellan. "It's not 100% effective, but little that we do in medicine is 100%."