Further championing the importance of vaccines in protecting children’s health and well-being, a quality improvement project recently completed by CHOC pediatricians successfully increased childhood immunization rates in Orange and Los Angeles counties. The project produced a number of QI strategies that could be replicated by pediatric providers across the country who are likewise seeking to improve immunization rates among their patients.

The project, funded by an American Academy of Pediatrics grant, focused on children ages 19 months to 35 months and their adherence to the Combo-10 portion of the AAP immunization schedule. The immunization panel known as Combo-10 includes DTaP, IPV, MMR, HiB, HepB, VZV, PCV, HepA, RV and Influenza vaccinations. The AAP’s immunization schedules outlines recommended ages for routine immunization administration.

Nationwide, the compliance rate for Combo-10 is between 40-50%. This means as many as half of U.S. children are not considered up to date on vaccinations, leaving them vulnerable to contracting these 10 illnesses the Combo-10 panel protects against.

“We sought to make sure that children ages 19-35 months were up-to-date with all immunizations they should have received by their age,” says Dr. Dan Kowabunpat, a CHOC pediatrician and project co-leader.

Participating in the project were 15 practices across CHOC’s Primary Care Network including 87 providers who collectively care for approximately 60,000 patients. Each practice sought to raise immunization rates 5% over baseline figures – a goal they would not only meet but succeed, with immunization rates raising 5.8% overall.

Also participating in the project were UCLA, Vanderbilt Children’s Hospital, Penn State Children’s Hospital, the Children’s Hospital at Oklahoma University Medical Center and Gundersen Health System.

Although a recent California law eliminating the possibility of a personal belief exemption for immunizations raised kindergarten vaccination rates, rates for younger children had remained low.

“Southern California’s vaccination rates skew low. CHOC’s Primary Care Network tends to have higher than average vaccination rates for our area with between 60% and 70% of our children fully immunized, but we recognized there was still work to be done to protect children,” says Dr. Eric Ball, a CHOC pediatrician and study co-leader.

The reason behind lower-than-desired immunization rates, per Dr. Ball, is not necessarily because parents don’t want to immunize.

“The fault lies with missed opportunity,” Dr. Ball says. “If a patient is sick during a visit, or if their well check was scheduled before they’re due for a vaccine, over time these missed opportunities build up and then we have kids who are not fully immunized.”

The quality improvement project, completed earlier this year, included both clinical education for staff, as well as strategies that could be replicated and implemented by other practices with similar goals.

Clinician education

• Physician learning sessions — Led by pediatric infectious disease experts from CHOC, these sessions provided vital education on both quality improvement efforts, as well as strategies for discussing the importance of vaccines with parents.
• Front-office staff learning sessions — While essential to practice operations, many of these clerical team members do not have formal medical training. As the first faces patients and parents see before their doctor, these staff members would routinely fields questions such as, “Am I getting shots today? Do I need this vaccine? What does this vaccine do?” With more comprehensive training, staff members were better able to speak to these topics, and curious patients and parents were more informed.

Monthly strategies

For the first three months of the project, participating practices implemented strategies aimed at boosting immunization rates outlined by project leaders. For subsequent months, each practice identified strategies based on their specific patient population and office dynamics. Proven strategies include:

• Checking eligibility at all visits — Providers began checking immunization eligibility at every non-sick visit, rather than just well-checks. For instance, if a patient visits their pediatrician for a sports physical, their doctor checks for vaccine eligibility and administers any necessary vaccines. Before this project, checking vaccine eligibility was only done at well checks, but 75% of appointments are not checkups.
• Implementing a recall system — In collaboration with CHOC’s information services department, each practice developed a recall program to identify patients who were not up to date on vaccinations. The practice would then send calls/texts/postcards to remind patients to come in for immunizations.
• Promoting staff vaccinations — Practices took this project as an opportunity to provide education that staff were receiving vaccinations, too. For example, each CHOC staff member’s employee badge features a color-coded sticker updated annually indicating they receive an influenza vaccine that year. New signs in some offices read, “If you see this sticker on my badge, it means I got my flu shot, just like you.”
• Waiting room activities — One practice created a flu quiz for patients to complete in the waiting room, as a way to start a conversation with kids about vaccines.
• Nurse appointments — Walk-in flu shot offerings were implemented with nurses. Historically, patients had to make an appointment with their pediatrician.
• One-on-one QI sessions — Quality improvement advisers from CHOC’s population health team held on-on-one sessions with providers to pour over their practice’s immunization rates and how it compared to other practices and discuss strategies for boosting immunization rates.
• Comfort measures — Comfort measures for immunization delivery, including distraction devices, sucrose solution for babies and mindfulness techniques for older children.
• Collaboration — CHOC physicians leaders collaborated with colleagues at participating sites around the country to share findings and best practices.