Pneumococcal Vaccination Achieving 100% Compliance Good Samaritan Health Center January 2007

Objectives Planning Stages –Data Analysis –Current State and Goals –Interventions Implementing Changes –Change Education Physicians Nursing Staff Other key stakeholders Monitoring Results –Data Analysis –Results Communication

Planning Stages Data Analysis Quarter Cumulative Data

Current State and Goals Current State (as of Q12005) –QI falling out badly 30 to 85% Compliance rate for 2004 –Using written notes to remind MDs Physician overlooked; many times not addressed Goals –Create a consistent way for screening –Make it easy for the Physicians Physicians stated “too time consuming” to write out orders in charts

Interventions Create a label to easily assess vaccination status Add prompt on Admissions Database to attach label to front of chart

Interventions

Interventions – Policy Creation During interview, RN asks vaccination questions Patient Sticker adhered to Pneumovax Stickers RN checks “did” or “did not” on sticker Unit Clerk checks RECIN for vaccination status –(Regional Early Childhood Immunization Network) If Yes, Physicians signs #1 and #2 –#1 to Pharmacy, #2 on Progress Notes If No due to previous vaccination –#3 is signed and placed into the progress notes If No due to Patient or Physician refusal –#4 is signed and placed into the progress notes

Implementing Changes Physicians –Medicine Committee –Infection Control –Medical Staff Committees Nursing –Unit Meetings Other Key Stakeholders –Unit Clerks

Monitoring Results Data Analysis

Monitoring Results Data Analysis –Q12005 to Q32005 Increasing Compliance More work necessary Results Communication –Q12005 to Q32005 Medical Staff Committee Meetings Nursing Unit Meetings

Monitoring Results Data Analysis –Communication and Reiteration Q42005 to Current – 100% Compliance

Summary Simple answers to tough questions –A small sticker goes a long way Analyzing processes to make them easier Meeting Physician needs increases compliance Any Questions???