1. 2016 AFIX Training Sudha Setty, MPH

2. Presenter Credentials Sudha Setty, MPH, has a Master of Public Health from the University of Minnesota School of Public Health. She has seven years of experience as an epidemiologist working with quality improvement activities and Immunization Information System data use. She is currently the AFIX/Quality Improvement Coordinator with the MIIC Operations Unit at the Minnesota Department of Health. 2

3. Objectives As a result of participating in this webinar, you will be: Familiar with the components of an AFIX visit. Able to complete AFIX paperwork. Able to identify resources to use during site visits to help answer questions or address challenges that arise. 3

4. Agenda Introduction to Continuous Quality Improvement Introduction to AFIX AFIX in Minnesota Assessment Feedback Incentives Information Exchange (X) Administrative Requirements and Resources 4

5. What is Continuous Quality Improvement (CQI)? Approach to quality management that builds upon traditional quality assurance methods: Focuses on the process of conducting business. Emphasizes organization and systems. Promotes the need for objective data to analyze and improve processes. 5

6. What does CQI involve? CQI commonly involves: A quality improvement team. Training. Mechanisms for selecting improvement opportunities. A process for analysis and redesign. 6

7. What is Assessment, Feedback, Incentives, and eXchange (AFIX)? A CDC continuous quality improvement process informed by research. Used for improving immunization rates and practices at the immunization provider level. Has both quantitative and qualitative components. 7

8. What does AFIX involve? AFIX involves: Face-to-face interaction. Sharing MIIC based immunization rates. Educating providers on the use of MIIC to improve immunization rates and practice. Maintaining contact with immunization champions at clinic site and/or system level. 8

9. AFIX in Minnesota In the past, AFIX visits were always combined with Minnesota Vaccines for Children program (MnVFC) site visits. MIIC and AFIX visit components were not always covered due to increased VFC site visit requirements. 2015 CDC site visit feedback: not enough emphasis on MIIC during VFC site visit. Starting in 2016, MIIC regional coordinators operate AFIX program. Regional coordinator can perform visits and/or work with county IPI advisors to perform visits. 9

10. AFIX and MIIC MIIC can support clinic improvement activities: Established 2000. Robust, mature immunization information system. Assessment Reports. Client Follow-Up. MIIC and AFIX history: MIIC-based AFIX assessment since mid-2000s. Assessment reports were redesigned and enhanced in 2010. 10

11. Minnesota AFIX Visit Components Assessment: MIIC Assessment Reports. Feedback: Face-to-face site visit. Incentives: Formal. Informal. Information Exchange (X): Follow-up contact. 3-6 months after face-to-face site visit. 11

12. AFIX Eligibility CDC recommendations: Active or suspended MnVFC participant. Provider serves a large population: Per CDC, large population is > 30 patients in the assessment age ranges. Smaller providers are equally eligible, but given time and staffing limits, prioritizing larger providers is acceptable. Low immunization coverage (MIIC-based rates). Provider requests AFIX visit. Provider has new staff that can use immunization- related training. Provider is a new VFC participant. 12

13. Clinic Lists Annual clinic lists take into account some CDC recommendations and Minnesota-specific standards. MIIC selection criteria: Provider type: Primary Care Clinic indicator. Immunization coverage rates for childhood and adolescent immunizations. Priorities assigned by MDH: Large population. Low immunization coverage. MnVFC status. Note: Priorities are not meant to be followed exactly. They are just a guide. 13

14. Assessment 14

15. Assessment Provides a standardized method for collecting and analyzing immunization data. These data provide valuable opportunities to understand immunization practice patterns. Purpose is to quantify a provider’s vaccination coverage and evaluate a provider’s immunization practices. 15

16. Minnesota AFIX Assessment Requirements Required Elements: Childhood Assessment: 4 DTaP, 3 IPV (Polio), 1 MMR, 3 Hib, 3 HepB, 1 VAR, 4 PCV13, 2-3 RV, Hep A. Childhood Series. Adolescent Assessment: 1 Tdap, 1 MCV4, MCV Booster, 1 HPV, 3 HPV. All elements are in MIIC Assessment Reports. Reports shared with provider must be run no more than 5 business days before feedback/initial site visit. 16

17. Feedback 17

18. Feedback Feedback, or the initial site visit, is the process of informing immunization providers and staff about observations and results from the assessment: Two-way conversation that links the quantitative and the qualitative elements of AFIX. Discussion should focus on putting clinic MIIC rates into practice context, advocating for MIIC use, understanding any current problems with clinic’s use of MIIC, and sharing resources to support clinic’s continued use of MIIC functions. Results in the development of quality improvement activities. 18

19. Pre-Visit Outreach Scheduling the initial visit: Offer a variety of days and times. Tell clinic that visit should take no more than 1.5 hours. All clinic staff that work in the clinic’s immunization work flow are welcome. Educate clinic staff on the content to expect during the visit and the expectations for clinic staff: Discussion of clinic rates. AFIX questionnaire. QI plan with two activities. Follow up contact in 3-6 months. 19

20. Pre-Visit Mailing Documents to send before visit: AFIX Questionnaire. Clinic staff may complete questionnaire before visit OR during visit with site visitor. Guidance on Questionnaire available on MIIC website. Immunization Assessment Reports. Run reports as of date of message to clinic contact. Instruct clinic to look at rates to determine if they reflect current internal clinic data. Send instructions on how to inactivate non-active patients from the clinic. Clinics may have different definitions of “active patient.” 20

21. Multiple Clinics at One Visit Minnesota has many health care systems of varying sizes. Health care systems frequently have one or two staff members in charge of quality improvement and data tracking for two or more sites within the system. It may make sense for the AFIX site visitor to meet with this person/team of people and discuss multiple clinics during one visit. 21

22. Preparing for Multiple Clinics at One Visit If you are planning to meet with one or two staff members in charge of multiple sites, please schedule a discussion with Sudha Setty at MDH. This approach may not be appropriate in all cases. Sudha will work with each region or site visitor that wishes to take this approach on a case by case basis. 22

23. Feedback Process: Assessment Reports Review Assessment Reports: Childhood. Adolescent. Talking points: Start with the positive. Above state average/at Healthy People 2020 goal. Point out highest rates for each vaccine. Transition gently into less positive. Areas for improvement: discuss lower vaccine coverage rates. Share anecdotes from other clinic encounters. 23

24. 24

25. 25

26. Feedback Process: Developing QI Objectives Review questionnaire, line by line: Each question should have “Yes” or “No” checked in appropriate columns. Help clinic select 2 objectives to improve: Can be childhood and/or adolescent. Clinic can make their own objectives based on their current improvement activities and/or organization goals in the “custom objectives” section. If clinic has not filled out questionnaire ahead of time, fill it out with them. Use the guide to site visit strategies to prepare for staff questions and to point staff in the direction of necessary resources. QI Project column should have two checked boxes by end of visit. 26

27. Assessment Questionnaire 27

28. Examples of QI Activities From real site visits, 2013 – present: Improve HPV rates by 5 percent within the next 6 months. Ensure that front desk staff remind patients to schedule next appointment. Use MIIC to determine when a patient’s immunizations are due at current visit. Schedule next vaccination visit before patient/parents leave clinic. Ensure that immunization champion has an active MIIC login. Regularly document vaccine refusals and reasons in EMR and/or in MIIC. Inactivate patients in MIIC no longer seen by practice. Contact no show patients/parents to reschedule a visit 3-5 days after the no show. 28

29. Feedback Process: Tips Clinic staff are sometimes reluctant to believe that MIIC rates reflect their patients’ true coverage. Talking points and resources: Clinic may be in line for real time data exchange and onboarding. Resource: MDH MIIC Help Desk. Clinic may have several inactive patients associated with their assessment denominator – MOGEs. Resource: Client Follow-Up user guidance. Clinic’s data may not be getting into MIIC accurately. Resource: MDH MIIC Help Desk. 29

30. Feedback Process: Tips Clinic EMRs may have the ability to generate immunization coverage reports based on EMR data. Clinic staff may question MIIC report relevance and accuracy if EMR reports show higher coverage. Tip: emphasize MIIC measures as the statewide source on immunization data. LPH and MDH use MIIC data to find immunization gaps. 30

31. Feedback Process: Tips Some clinics may already have excellent immunization coverage, well above the state average and/or reaching Healthy People 2020 goals. If childhood immunization rates are high, switch conversation focus to adolescent immunization. Statewide HPV coverage is well below HP 2020 goals. Tdap and MCV4 are required for school entry. If childhood and adolescent immunization rates are high and clinic sees adults, run adult assessment report. Not AFIX required, but can help clinic use their excellent practices across all ages. If all ages are high, your work is done! 31

32. Feedback Process: Follow-Up Plan and Resources Follow-up plan: Notify clinic about the follow up contact in 3-6 months. Will check progress with QI plan and implementation. Will go over new immunization rates and compare to rates from site visit. Resources to leave with clinic: Be creative! CDC. MDH. Region-specific materials. 32

33. Feedback Process: Documentation Submit the following documentation to MDH: Childhood and/or adolescent assessment reports. Completed Immunization Assessment Questionnaire: Must indicate which immunization improvement activities clinic is doing and not doing (using yes/no checkboxes). Must indicate which objectives clinic chooses to improve (using QI plan column). 33

34. Incentives 34

35. Incentives Used to motivate providers or immunization staff to develop more effective immunization delivery systems and ultimately improve immunization coverage levels: Promote change. Reward achievement. Two types: informal and formal. No requirements or paperwork for this component. 35

36. Informal Incentives Free immunization materials. Educational in-services for staff. Ongoing immunization updates. Assistance with developing an immunization quality improvement plan for the office. Letters of recommendation. Site visitor can use and distribute MDH, CDC, and other QI resources as informal incentives. 36

37. Informal Incentive Examples Examples from other states: Inter-Clinic competition. Clinics that share a building keep penny jars for number of vaccines given. Pennies donated. Winning clinic gets prize from other participating clinics. Letters of recommendation from local public health jurisdiction. Published in local papers. 37

38. Formal Incentives Certificates of participation, improvement, and collaboration. Promotion of clinics/offices as “Immunization Champions” or role models. Recognition of clinics/offices with significant improvement or high coverage levels at local or state conferences, educational seminars, and/or professional meetings. 38

39. Formal Incentive Examples Current awards: National: The CDC Childhood Immunization Champion Award. MN Specific: Coverage awards. G. Scott Giebink Award for Excellence in Immunization. Regions may develop their own awards for excellence. 39

40. Information Exchange (X) 40

41. Information Exchange (X) Involves contacting providers to monitor and support progress on the quality improvement strategies discussed during the initial site visit. Helps maintain continuous quality improvement. Gives support and resources to providers to improve the quality of their immunization services. 41

42. Follow-Up Contact Every provider who receives an AFIX visit receives an initial follow-up no later than 6 months post-visit. The purpose of this follow-up is: To discuss and document a provider’s progress on implementing the agreed upon QI strategies. To provide any clarifications and technical assistance. 42

43. Preparing for Information Exchange (X) Schedule contact: Face-to-face. Conference call/webinar. Template slides available for use. Run new rates: Childhood/Adolescent Assessment Reports for the same age group considered in initial site visit. Use custom reports to adjust age range. Assessment date: “today.” 43

44. Requirements for Follow-Up: Rates Re-run the assessment rates for the same birth date range from initial visit. Same vaccines for childhood and adolescent. Use the “Custom Reports” function in MIIC Assessment. Review and compare new rates and site visit rates with clinic staff. 44

45. Requirements for Follow-Up: QI Activities Check on progress made on QI activities from initial visit. Progress should be documented as follows on the AFIX follow-up form: Fully implemented (100% complete). Progress to full implementation (> 50% complete). Partially implemented (< 50% complete). No implementation (0%). Send follow-up form to MDH after follow-up contact is complete. For progress reported at less than 100% complete, request an estimated date for 100% completion. Subsequent follow-up contact can be via email, conference call, or in person. Once clinic has reported 100% implementation, resubmit follow- up form to MDH. 45

46. One Information Exchange (X) for Multiple Clinics Covering multiple clinics with one follow-up contact may be allowed after consultation with MDH. If you are planning to meet with one clinic manager or QI specialist for follow-up on multiple sites, please consult with Sudha. If you completed one initial visit for multiple sites and wish to do the same for the follow-up, you must still consult with Sudha. 46

47. Administrative Requirements and Resources 47

48. Visit Tracking and Timeline Regions should track the progress of their AFIX clinic visits using the AFIX Visit Tracking Template. Bold fields are required. Other fields are as needed. Regions may add fields to their individual tracking lists as needed. All initial visits should take place in calendar year 2016. Follow-up contact to complete visits may take place within first 3 months of 2017. 48

49. AFIX Paperwork Send initial visit and follow-up paperwork to MDH AFIX mailbox within 10 business days of contact. Email: Health.AFIX.Mailbox@state.mn.us.Health.AFIX.Mailbox@state.mn.us Mailbox monitored by Sudha and data entry staff. AFIX questions can also be sent to this mailbox. 49

50. AFIX Resources CDC: AFIX: http://www.cdc.gov/vaccines/programs/afix/index.html. http://www.cdc.gov/vaccines/programs/afix/index.html MDH: AFIX: http://www.health.state.mn.us/divs/idepc/immunize/registry /afix.html. http://www.health.state.mn.us/divs/idepc/immunize/registry /afix.html QI Toolbox: http://www.health.state.mn.us/divs/opi/qi/toolbox/. http://www.health.state.mn.us/divs/opi/qi/toolbox/ Office of Performance Improvement: http://www.health.state.mn.us/divs/opi/. http://www.health.state.mn.us/divs/opi/ QI Resources: Community Guide, Vaccinations section: http://www.thecommunityguide.org/vaccines/index.html. http://www.thecommunityguide.org/vaccines/index.html 50

51. Questions? Contact Sudha Setty, AFIX/QI Coordinator: Sudha.setty@state.mn.us. Sudha.setty@state.mn.us 651-201-5551. 51