Strong administrative buy-in, firm mandates can push flu vaccination rates up to more than 99% among health care workers
Experts urge hospital leaders to promote flu vaccination as a patient safety initiative
November 1, 2014
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Executive Summary
While flu vaccination rates are inching up among health care workers, there is still room for improvement. The Centers for Disease Control and Prevention reports that slightly more than 75% of health care workers received the flu vaccination during the 2013-14 season — an increase of roughly 3% over the 2012-13 season. However, some hospitals have been able to achieve vaccination rates in excess of 99%. The apparent key to these efforts is a firm mandate that all personnel receive a flu shot as a condition of employment. There is always pushback to such policies, but hospitals report that most personnel eventually come around.
- While flu vaccination rates are on the increase among health care personnel, data from the Centers for Medicare and Medicaid Services (CMS) note that rates vary widely from state to state. For example, the vaccination rate for health care workers in New Jersey stood at just 62% last year. In contrast, more than 95% of health care workers in Maryland received the shot during the 2013-14 flu season.
- Both Loyola University Medical Center and Henry Ford Hospital have been able to boost flu vaccination rates among their health care workers to more than 99% with the implementation of policies that require flu shots as a condition of employment.
- Experts say successful flu vaccination campaigns require strong administration buy-in and physician leadership.
There is new evidence that health care workers are increasingly opting to receive yearly flu vaccinations, as recommended by the CDC, The Centers for Medicare and Medicaid Services (CMS), The Joint Commission, and many other public health agencies. The CDC reports that last year (2013-14), slightly more than 75% of all health care workers received the vaccination — roughly a 3% increase from the 2012-13 flu season. The findings are based on a web-based survey of health care workers conducted in April of 2014.1
The data are similar to findings from CMS, showing that nearly 82% of hospital-based workers received the flu vaccination last year. These totals, which are based on information provided by more than 4,000 hospitals that participate in the Hospital Inpatient Quality Reporting Program, also show that 90% of physicians and nurses got the shots in 2013-14.2
While the overall progress is welcome news to public health agencies that have been strongly pushing for all health care workers to be vaccinated in recent years, the vaccination rates vary widely by state. For instance, the CMS data show that vaccination rates for health care workers last year stood at just 62% in New Jersey and 64% in Florida. At the other end of the spectrum, more than 95% of health care workers received the flu vaccinations in Maryland.
Clearly, there is still ample room for improvement in many areas, and there is no question that pockets of resistance remain. However, some hospitals have shown that flu vaccination rates in excess of 99% are possible when administrators make the issue a top priority and put resources in place to get the job done.
Consider a firm mandate
Loyola University Medical Center (LUMC) in Maywood, IL, was among the first hospitals in the country to make flu vaccinations mandatory as a condition of employment six years ago. At the time, the flu vaccination rate for hospital staff stood at 72% — above average for the country during that period, but not where hospital administrators wanted to be.
"Everybody was just concerned about promoting a safe and healthy environment for our patients and for our staff," explains Carol Schleffendorf, RN, MS, NE-BC, the administrative director of Burn/Trauma at LUMC and the person who has taken charge of the flu vaccination campaign from its inception. "We recognized that if we had a healthy staff we could provide consistent care to our patients, and we would also keep our patients safe because we were healthy."
To kick off the campaign, the hospital integrated flu vaccinations into its disaster drill process, but there was significant pushback. "Primarily people just felt like they were being forced to do something against their will," recalls Schleffendorf.
Administrators developed a process in which employees could seek medical or religious exemptions from the flu shots, but otherwise, the hospital’s position was firm. "We told people that they had a choice. They could take the vaccination or not, but we did put in there that their employment would be contingent on having a mandatory flu shot," says Schleffendorf.
Developers of the approach were concerned that they could potentially lose a number of employees from the policy, but in the end, only 0.1% chose to leave the hospital rather than be vaccinated that first year, and the number of employees making this choice has declined even further since that time. Now, any new hires understand at the start of their employment that getting a yearly flu shot is part of the package, explains Schleffendorf.
The mandatory flu shot policy has certainly delivered: Vaccination rates have exceeded 99% since the first year of the firm approach. Further, over time, opposition to the policy has greatly diminished. "Organizationally there is not even a question anymore. People are willing and ready," notes Schleffendorf. "If we are not careful to explain exactly where people can get their shots, there can easily be 200 people lined up outside the employee health clinic on the first day, so we take great pains to make sure we have multiple sites, clear communication, and consistent communication [throughout the campaign]."
Assemble a multi-disciplinary team
With six years of experience in delivering the flu shots, the hospital is also now able to carry out the flu shot campaign much more quickly and efficiently than it did the first year. "In the beginning, our program stretched out over about 14 weeks, so we started in October and went almost all the way until Christmas," explains Schleffendorf. "This year we will be doing it in 30 days, so that is 7,000 people [getting vaccinated] in 30 days."
One big step that has helped to streamline the documentation process that goes along with the flu shots: The hospital replaced what had been a manual, paper-based process with a process that utilizes scanners that can electronically document that an employee has received the shot. "Once an employee’s badge is scanned, the information goes automatically into his or her record," explains Schleffendorf. "We have people who are trained to use the scanner, and it is very simple."
To make the flu shots widely accessible to individual units like the ED, for example, the vaccine and a scanner will be provided to the unit for a period of eight days during which the shots will be available to staff on a 24/7 basis, notes Schleffendorf. "In the ED, as on all floors, there is absolute accessibility to the flu vaccine. People can get it at 2 a.m., 2 p.m., or any time," she says. "Then we monitor progress every week to see the status of compliance throughout the organization."
While the process of getting everyone vaccinated works swiftly now, Schleffendorf acknowledges that it took a few years to work the kinks out of the system. "It sounds simple, but it was a lot of hard work getting the program to this point, and every year we find something that we want to do differently with it," she says.
Schleffendorf adds that carrying out the campaign each year requires a multidisciplinary team that includes representatives from throughout the organization, including human resources, employee health, pharmacy, and the medical staff. And she emphasizes that there can never be enough communication about the program.
Schleffendorf explains that she utilizes videos, computer notices, and flat screens posted throughout the hospital to keep hospital staff abreast of where and when the flu shots are being delivered on a daily basis during the campaign. However, now that the program is in its sixth year, employees do have a good understanding of why the flu shots are important and how the program works. "I don’t find myself having to go through the whole explanation as much anymore," she says. "There is always a small subset of people who want to be the very last ones to get the flu shot, but they all get it."
Mask-compliance is problematic
Infectious disease experts at Henry Ford Hospital in Detroit, MI, have also found that the implementation of a mandatory flu vaccination policy is key to achieving the kind of maximum coverage that can insure patient and staff safety.
"There is a lot of data in the literature showing that health care workers have been associated with outbreaks in health care facilities. And it is also known that viruses shed 24 hours before people are symptomatic, so if you just rely on people getting immunized and going home if they are sick, it is too late," explains Allison Weinmann, MD, an infectious disease physician at Henry Ford Hospital. "What we are trying to do is help address the epidemic of influenza in our nation by making sure our health care workers are immunized, and that we are not a source of infection."
The hospital began its push to increase vaccination rates in 2010 with what Weinmann describes as a soft mandate. The policy applied to just clinical staff, and it enabled employees to opt out of receiving the flu shot, but they had to sign a declination form, and they had to wear a mask if they were within six feet of a patient, she explains.
"What happened was we had to do compliance rounds to make sure people were wearing the masks. We put a blue sticker on everyone who was immunized," observes Weinmann. "We were hoping that the threat of having to wear a mask would be a disincentive, and that people would go ahead and get immunized, but that is not what happened. What we found is that people were very creative in finding ways not to wear the masks."
Another problem with the approach was that patients did not like the masks — even when practitioners explained to them that they were wearing the masks to protect patients. Also, immunized employees didn’t want to be in meetings with unimmunized employees, recalls Weinmann.
In the second year of the policy, the hospital tweaked the program to include both clinical and non-clinical staff, and made some other adjustments, but the problems with the masks and compliance remained, and the flu vaccination rates still weren’t where the hospital wanted them to be. "We got up to about 87% in the second year, but we wanted close to 100% vaccinated so that we could rely on herd immunity for the few people who weren’t immunized," notes Weinmann.
Address misinformation
Consequently, in the third year of the program, the 2013-14 flu season, administrators decided to lose the masks and the stickers, and simply mandate the flu vaccinations for everyone as a condition of continued employment. A process was put into place for medical or religious exemptions, but no longer would people be able to simply opt out by signing a form and wearing a mask. "We knew from the literature that we would have very few medical or religious exemptions, and that is what happened," says Weinmann.
By this time, most of the staff had already bought into the program and were getting their flu vaccinations, but the mandate pushed vaccination rates to at least 99%. "We finally cracked the code of what was successful for us," notes Weinmann. "Our administration was hugely supportive. It costs a lot of money to vaccinate 23,000 health care workers [in the health care system], and to have the staff to vaccinate them."
Along with administrative support, the program was facilitated by human resources and employee health. "If we hadn’t had all these groups working together it wouldn’t have happened," stresses Weinmann.
Also key to the effort was a significant educational component focused on dispelling all the mis-information that circulates about the flu vaccine. "We are talking about [vaccinating] not just physicians and nurses, but all levels of employment, from environmental services to students and vendors," says Weinmann. "And there are a lot of myths about the influenza vaccine."
For instance, Weinmann notes that people need to understand that they cannot contract influenza from the vaccine, and that it does not cause harmful conditions such as autism. To provide this information, Weinmann and other infectious disease professionals spent a lot of time reaching out in the early days of the vaccination program. "We went to meet and greets, lunch and learns, and if we were invited to meet with different employment groups, we met with them," she says. "A lot of it was just reassurance. This is the data, it is not a harmful vaccine."
Further, Weinmann states that since most people go into health care with some sort of altruistic streak, they respond to the idea that the flu vaccine does not just protect them, but also their patients, their families, and the community. "I think the education helped some people, and in the end, the few people who couldn’t be moved by the education and just felt it was being forced on them ultimately had a choice: they could capitulate and get immunized or they could be terminated," she says. "In the end, almost everyone got immunized."
What also helped win employees over was the fact that by the time the hospital had implemented its hard mandate on flu vaccinations, most of the other hospitals in the region had implemented some type of flu vaccination requirement as well. "I think people saw the writing on the wall. If they were going to leave our health system and go to some other system in the area, they would end up with the same problem," says Weinmann. "Health care workers speak their minds about things, and they did. But the vast majority of people went along with it, [they] saw the science and the logic in it, and the value in terms of patient safety."
Get physicians on board
Reflecting on the success of the flu vaccination effort, Weinmann says there were several strategic decisions that other health care organizations can learn from. First, she advises the leaders of this type of campaign to get hospital administrators on their side first. "We realized immediately that if administration didn’t buy into the whole thing and purchase and put aside resources for it, it wasn’t going to happen," she explains. "We went to a lot of committee [meetings] with the CEO, the CMO, and the CNOs, and really talked to them about it. We got immediate buy-in from them, which was great."
Also, make sure your health system’s influenza committee is large and robust, including a number of key players, as well as representation from all sides, says Weinmann. "We had employee health represented, infectious disease, human resources, pharmacy, and public relations," she says. "People then went back to their sites with information."
Weinmann adds that she doesn’t think the campaign would have been successful if it hadn’t been spearheaded by physicians as a patient safety initiative. "I think ultimately if you say it is a patient safety mandate, and that is the reason you are doing it — and it is the reason — eventually people come around," she explains. "Also, physicians are loud and tend to take whoever is around them with them."
References
- Black C, Yue X, Ball S, et al. Influenza vaccination coverage among health care personnel — United States, 2013-14. Morbidity and Mortality Weekly Report, Centers for Disease Control and Prevention, September 19, 2014; 63:805-811.
- Lindley M, Bridges C, Strikas R, et al. Influenza vaccination performance measurement among acute care hospital-based health care personnel – United States, 2013-14 influenza season. Morbidity and Mortality Weekly Report, Centers for Disease Control and Prevention, September 19, 2014; 63:812-815.
SOURCES
- Carol Schleffendorf, RN, MS, NE-BC, Administrative Director, Burn/Trauma, Loyola University Medical Center, Maywood, IL. E-mail: [email protected].
- Allison Weinmann, MD, Infectious Disease Physician, Henry Ford Hospital, Detroit, MI. E-mail: [email protected].
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