Are you flu-shot ready?

TJC rules on staff vaccines in effect now

By 2020, all accredited hospitals are supposed to achieve a 90% success rate for flu vaccinations among staff. And while that might seem like a long time from now, some organizations are already having a tough time convincing staff to roll up their sleeves for a shot. The notion of mandating these vaccines sits ill with some people on principle, regardless of the scientific studies that show it's vital to patient safety.

According to the requirements that went into effect in July, accredited organizations must do the following:

  1. Establish a flu vaccination program.
  2. Educate staff and independent licensed practitioners about the vaccine, non-vaccine control and prevention measures; and diagnosis, transmission and impact of flu.
  3. Provide vaccines at places and times that are accessible to staff.
  4. Have a plan for improving vaccination rates.
  5. Set incremental goals to reach 90% by 2020.
  6. Have a description of how you determine vaccination rates.
  7. Evaluate reasons given for refusing vaccines at least once a year.
  8. Improve rates of vaccination annually towards your goal.
  9. Provide rate data to stakeholders.

The plan is already under way at MedStar Health, which serves the Baltimore/Washington, DC, area, says Lynne Karanfil, RN, MA, CIC, the corporate director for infection prevention at the Columbia, MD-based organization.

It began as a patient safety initiative in 2006, she says. It included a vaccination declination process, but they still managed to significantly increase vaccination rates from what she calls an "unacceptable" level of 54% among healthcare workers. "We conducted a review of the literature, which indicated evidence to enact a mandatory program. A proposal was developed to move to a mandatory vaccination program, which was presented to our executive leadership, who decided to mandate influenza vaccinations to protect our patients. A multidisciplinary committee was formed to develop an implementation plan and influenza vaccination policy."

Three summers ago, they adopted the mandatory program, requiring all associates, physicians, other credentialed medical staff, volunteers, contracted staff, and vendors to be vaccinated for influenza unless they had a medical contraindication or religious exemption, says Karanfil. "Failure to comply with the policy would result in disciplinary action for associates, up to and including termination."

They were one of the first systems in the country that mandated vaccinations by both associates/staff and physicians. Without both, an element of improving patient safety would be missing. Key to the success of the plan, though, was education and communication designed to change the minds of people who weren't sure it was a good idea.

"Anyone who has concerns about the mandate can discuss their concerns with occupational health, an infection preventionist, or their manager," she says. "There is also an online education program that addresses concerns."

A database tracks vaccinations through the occupational health department. Reports are sent on to managers to help them track compliance. Vendors are tracked through a different database. They provide free vaccinations during scheduled sessions to make the vaccines convenient.

All of this was done before the rule by TJC related to flu vaccines was final. But now that others will be creating programs to address the requirement, Karanfil says that there are ways to improve the odds of success. First and foremost are education and communication. "The communication plan included the development of comprehensive education material for associates and physicians to help dispel myths and misconceptions about flu," she says. "Additionally, by requiring anyone who entered a MedStar entity to be vaccinated — with the exception of visitors and patients — we helped to ensure the safety of our patients, our first and highest priority."

Strong leadership was another factor, and she recommends having a physician leader champion the program to help alleviate concerns among the doctors in your facility.

More information on improving staff vaccination rates is available on The Joint Commission's requirement at

For more information on this story, contact Lynne Karanfil, RN, MA, CIC, Corporate Director, Infection Prevention, MedStar Health, Columbia, MD.