Improving pediatric immunization rates in a safety-net delivery system Denver Health wins 2006 JCAHO Codman Quality Award

Colorado Nurse, March, 2007 by Anne L. Hammer, Vickie J. Leger

Note: Denver Health & Hospital Authority Community Health Services was recently honored as a Joint Commission on Healthcare Accreditation (JCAHO) national Codman Award Winner for improvement of pediatric immunization rates. Named for the physician regarded in health care as the "father of outcomes measurement," the Ernest Amory Codman Award showcases the effective use of performance measurement by health care organizations to improve the quality and safety of health care.

Immunizations provide protection against vaccine-preventable diseases, thus promoting patient health, public health, and decreasing costs associated with illness. The estimated savings associated with pediatric vaccines are $6.30 of direct savings and $18.42 indirect for each dollar spent on vaccine delivery. Universal vaccination is a critical component of quality health care and is best accomplished through routine and intensive vaccination programs implemented in ambulatory primary care and public health clinics.

Denver Community Health Services identified the need to increase childhood immunization rates in the high-risk pediatric population served through their safety-net delivery system. Denver Health is a comprehensive, integrated healthcare organization with multiple components including a network of nine Family Health Centers (primary care clinics) in the low-income communities of Denver. Denver Health is the primary provider of care to the low-income populations in the city and county of Denver and serves approximately 35% of Denver's children.

Denver Health's initiative stemmed from an assessment that showed low immunization rates at its primary care sites were putting the community at risk for diseases that can easily be prevented. Beginning in 1993, the organization sought to change this trend by developing an initiative that included multiple strategies known to improve pediatric immunization rates. The key methods to improve vaccine rates were to accurately track patients, to regularly assess immunization levels, and to improve the on-time delivery of vaccines in primary care clinics.

The initiative targeted children < 3 years of age with at least one medical visit to a primary care clinic and spanned 1995 through 2005. As a result, immunization rates improved by 46 percent for two-year old patients and by 26 percent for one-year old patients. Denver Community Health Services achieved documented immunization rates of 84% for the childhood 4-3-1-3-3 series (4 DTaP, 3 Polio, 1 MMR, 3 Hib, 3 Hepatitis B vaccines by age 24 months) and 92% coverage for the 3-2-2-2 series (3 DTaP, 2 Polio, 2 Hib, 2 Hepatitis B vaccines by age 12 months).

A successful initiative includes a well-defined and executed process, along with the support of those involved with day-to-day operations. Nursing played a critical role in assuring that processes were developed with input from stakeholders. From the first steps of problem identification, throughout the design, implementation, and review of outcomes, nursing involvement assured a user-friendly project, leading to improved patient outcomes.

Leaders from throughout the Denver Health & Hospital Authority agency including Community Health, Public Health, Inpatient Newborn Nursery and Information Services divisions were involved in the planning of the initiative and commitment of resources. Site-specific physician and nursing leaders and their immunization teams implemented the initiative at their clinic sites. Immunization teams included clinical and clerical staff and the designated nursing immunization "champion" (local resource for staff members regarding immunizations and the recommended schedule, immunization registry superuser, and responsible for maintaining the clinic's vaccine inventory). The initiative was implemented at all Denver Community Health Services primary care clinics (9 Family Health Centers), with additional Denver Health immunization registry participation from the Public Health Immunization Clinic, Inpatient Newborn Nursery, network of 12 School-Based Health Centers, on-campus Pediatric Urgent Care Center and Immunization Outreach Clinic projects at 15 sites.

The Immunization Program RN and Data Entry Clerk served, and continue to serve, as immunization resources to the agency's clinical and clerical staff. They provide registry training and ongoing support, distribute the monthly reminder/recall lists and postcards, communicate updated immunization information to staff, and assist with team immunization quality improvement projects.

Site-based process improvement activities included:

* Quarterly immunization rate assessments using nationally standardized CDC Clinic Assessment Software Application (CASA) program

* Semiannual immunization team meetings facilitated by staff trained in the Plan, Do, Study, Act (PDSA) format

* Reminder/Recall activities including lists of children behind on vaccines and postcards mailed to their parents

* Development and sharing of immunization "best practices" amongst sites