1. AFIX Standards: a new programmatic tool
Nancy Fenlon, RN, MS
Program Operations Branch
ISD/NIP/CDC
National Immunization Conference
March 2005

2. Learning Objectives
By the end of the presentation participants will be able to:
Describe the rationale for the development of the AFIX Standards
Describe the different components of the AFIX Standards
Know how to request technical assistance from the CDC on implementing the AFIX Standards into their immunization programs
I want to thank everyone for attending this workshop session. The goal my presentation today is to provide background on why the standards were developed, present a high level overview of the AFIX Standards and leave you with some information on how to get assistance when your program starts to “tackle” the standards.

3. A Brief History
Observations made by NIP staff based on interaction with grantees found:
Implementation of the AFIX program among grantees was extremely diverse
At times, implementation of AFIX within a grantee program was extremely diverse
During contacts with grantees, NIP staff found that how AFIX is implemented is very diverse among the grantees and at times implementation of AFIX was very diverse within a single grantee program. For example, the number of charts used for the assessment varied among the field staff or the assessment method varied without any formal documentation for using different methods.

4. A Brief History (continued)
Discussion with external members of the Clinic/Provider Assessment Workgroup (CPAWG) concluded:
The Immunization Program Operations Manual (IPOM) provided limited information on how to plan, implement and evaluate AFIX
Core Elements Document provided a foundation on how to implement an AFIX visit at a provider level but did not provide significant programmatic guidance
These observations were discussed at the fall 2003 Clinic/Provider Assessment Workgroup (CPAWG) meeting. CPAWG is workgroup comprised of NIP staff who work on AFIX activities and six external that meet twice a year to discuss and provide input on VFC/AFIX activities.
The external CPAWG members made the following observations:
The Immunization Program Operations Manual (IPOM) provided limited information on how to plan, implement and evaluate AFIX
Core Elements Document provided a foundation on how to implement an AFIX visit at a provider level but did not provide significant programmatic guidance

5. Goals and Objectives of the Standards Document
To provide information and guidance to grantees on the components necessary to implement a well-designed AFIX program
To develop a basic level of standardization of the AFIX process across all grantees
To encourage grantees to use well-developed AFIX programs to initiate new and innovative methods for collaboration to improve immunization delivery systems
At the fall 2003 meeting, the CPAWG committee was tasked to develop standards for the “AFIX” process. The goals and objectives of this document are:
To provide information and guidance to grantees on the components necessary to implement a well-designed AFIX program
To develop a basic level of standardization of the AFIX process across all grantees
To encourage grantees to use well-developed AFIX programs to test new and innovative methods for collaboration to improve immunization service delivery
The draft of the Level I Standards were distributed at the 2004 NIC.

6. The Structure of the AFIX Standards
Levels (3)
Components (6)
Program Operations
Assessment
Feedback
Incentives
eXchange
Program Evaluation
This slide diagrams the structure of the AFIX Standards. The Standards format is loosely based on the Registry’s PROW document.
The Standards have three levels creatively named Level I, II and III. Each Level builds upon activities from the previous levels.
Under each level there are 6 components. Four are very familiar to AFIX staff- Assessment, Feedback, Incentive and Exchange of Information. The two additional components are Program Operations and Evaluation.
Every Component within each level has a number of Standards that programs must meet to achieve completion of each level.
Each level has a self assessment tool that programs can use to measure their progress toward achieving the standards in each of the three levels.
The Standards document also provides other resources for programs to review, use or modify if desired.
Standards
Standards
Standards
Standards
Standards
Standards
Self-Assessment Tools
Other Resources

7. A closer look at the Standards by the Levels
Level I
A well planned program that addresses the basic components of the grant requirements
Level II
A program improving on “good.” Level II focuses on refining policies and procedures and increasing AFIX activities (collaborations and/or sites visited)
Level III
A program that conducts continuous quality improvement on itself. Level III focuses on achieving, and maintaining objectives and evaluating AFIX activities to improve the process
So what will an AFIX program look like when it achieves all the Standards with in Level I, Level II or Level III?
A program that achieves all Level I standards will have a well planned AFIX program that addresses the basic components of the grant requirements. The AFIX program has identified objectives, a written strategic plan to meet the identified objectives and are implementing policies and procedures as part of the strategic plan to meet the identified objectives.
A program that achieves all Level II standards will have a program that has improved on “good.” Level II focuses on refining policies and procedures and increasing AFIX activities (collaborations and/or sites visited)
A program that achieves all Level III standards will have a program that conducts continuous quality improvement on itself. Level III focuses on achieving, and maintaining objectives and evaluating AFIX activities to improve the process

8. Program Operations through the Levels
Program Operations Component Standards
Level I (9 Standards)
Program planning
Staff development
Provider recruitment
Planning for collaboration with external organizations
Level II (3 Standards)
Protocol and job descriptions reviewed and revised annually
Feasibility of combining VFC/AFIX visits or increasing efficiency of combined visits
Establish action plan with outside organization/agency to collaborate on AFIX activities
Now let’s review each Component and its standards. I will start with Program Operations Level I has 9 standards that focus on the development of basic program needs that includes:
Program planning and evaluation through development both long and short-term objectives
Provider recruitment and site visit goals
Staff development that includes written job descriptions, staff training policies/procedures and monitoring of staff activities
Planning for collaboration with external organizations
Level II has 3 Standards
Requires programs to review and revise all AFIX related protocols annually.
If programs are not conducting combined visits to evaluate the feasibility to begin. If programs are conducting combined visits then focus on increasing the number of providers visited
Establishing a collaboration related to AFIX with an external agency.

9. Program Operations through the Levels
Level III (4 Standards)
Focus on achievement of Healthy People 2010 Immunization Objectives
Expand collaborations
Mentor providers who want to conduct self-assessments
Initiate collaborations with other programs within the health department
Level III of Program Operations focuses on maintaining all Level I and Level II standards; as well as the implementing the following standards:
Achieving Healthy People 2010 assessment goal
Expand collaborations to other health care organizations to reduce provider burden related record reviews
Mentor VFC providers who want establish self assessments
Initiate collaboration with other programs within the health department

10. Assessment through the Levels
Level I (5 Standards)
Written Protocols available to the field staff
Provider communication
Assessment methodology
Sample selection
Quality Assurance of assessment protocols
Level II (2 Standards)
Continue to monitor, review and update assessment polices and staff activities
Develop plan to possibly use Registry data for Assessments
If no viable Registry available establish regular contact with Registry staff and document encounters
Level I standards for the assessment component focuses on the development of written protocols that provides the procedures for conducting an assessment including:
Information on how to contact a provider
How to pull a sample
How to conduct an assessment
How will program monitor assessment activities for quality assurance purposes
Level II Standards for the Assessment component include
Reviewing and revising assessment protocols annually
Developing a plan to implement Registry based assessments
Develop on-going relationship with registry personnel if location does not have a viable registry currently

11. Assessment through the Levels
Level III (2 Standards)
Expand assessment activities to include adolescents and adults and have written policies for all assessed age groups
Use of registry data for assessments in public and private provider offices
Determine what provider sites will be assessed using registry data
Develop and implement protocols for monitoring quality of registry data used for assessments
Level III Standards for Assessment includes:
Expanding assessment activities to other significant age groups adolescents and adults
Implement registry assessments in both public and private sites
Develop and Implement protocols for monitoring of quality of registry data

12. Feedback Through the Levels
Level I (6 Standards)
Written Protocols for field staff
Scheduling feedback sessions
Content of sessions
Developing an immunization quality improvement plan with office staff
Post-feedback session follow-up
Evaluation
Level I Feedback Standards focuses on providing written protocols to staff on how to conduct a feedback session, evaluate the session and how to follow up with the office after the conclusion of the feedback session

13. Feedback Through the Levels
Level II (3 Standards)
Make AFIX a CQI process at the provider level
Document all follow-up activities with provider as determined by your program
Continue to review and update resource materials used with providers
Level II Feedback Standards focuses on making AFIX an on-going CQI process at the provider level.
At this level, once a program is successful with improving one area of opportunity for improvement; additional identified areas for improvement should begin the CQI process.
All follow up activities conducted with providers should be document as determined by the program and provide copies as appropriate to the provider.
Continue to review and update resources used at the provider level

14. Feedback Through the Levels
Level III (3 Standards)
Explore and pilot innovative methods for engaging providers and presenting information in feedback sessions
Provide assistance to providers who are not able to document progress with areas targeted for improvement
Document feedback policies and procedures for each age group if feedback procedures differ with the age groups
Feedback Standards for Level III encourage programs to become creative on how to present feedback information to providers and staff and how encourage providers and their staff to actively participate in feedback sessions.
Level III programs should develop methods to provide assistance to providers who receive AFIX visits but continue to struggle with low coverage levels or ineffective immunization delivery practices.
Document all feedback protocol or policies if the protocol and procedures differ by age group

15. Incentives through the Levels
Level I (4 Standards)
Develop and use informal incentives to motivate providers and staff
Develop and use formal incentives to recognize improved and/or sustained high coverage levels
Level II (3 Standards)
Document use of “informal” incentives at the provider level
Partner with other organizations to implement incentives
Develop and implement a program of incentives offered to low performing practices to improve coverage levels
The Incentives Standards focus on acknowledging what many grantees have been doing years but not recognizing the value or taking credit for their activities using informal incentives. Informal incentives can be as simple as providing the most up-to-date immunization schedule or as complex as helping an office set up a reminder recall system. Level I Standards require grantees to develop both informal and formal incentive protocols to use with their providers.
Level II Incentives Standards require grantees to document what informal incentives are being used at the provider level and provider’s acceptance of these informal incentives. Encourages collaboration of external organizations or partners to assist with incentives.
Develop incentive programs that target low performing practices to improve immunization coverage levels.

16. Incentives through the Levels
Level III (1 Standard)
Document incentive protocol for each age group assessed if different incentives are used for different age groups
Level III Incentives Standards are to document incentive protocol for each age group if incentives offered are different for each age group.

17. eXchange of information through the Levels
Level I (2 Standards)
Exchange of information during feedback
Exchange of information to promote AFIX at larger meetings
Level II (2 Standards)
Document interventions implemented and outcomes
Develop and implement plan to recruit high performing offices to become “immunization champions” to promote the AFIX process
Historically exchange of information was promoted as formal peer to peer discussion-generally conducted by an “immunization champion.” NIP recognizes that immunization champions are developed over a period of time and that significant amounts of information regarding immunization improvement and best practices are exchanged informally between the AFIX field staff and providers during the feedback session. The Level I Exchange of Information Standards focus on recognizing the informal exchange of information during the feedback session and promotes the start of a formal process to exchange information at a larger public health gathering.
Level II Standards focus on building a knowledge base of best practices at the grantee level by documenting interventions implemented to improve immunization services and the outcomes of the interventions. The information collected in this data base can be shared at many different levels ranging from the local provider to the state/national level.
Level II encourages starting the process to develop “Immunization Champions” to promote the AFIX process.

18. eXchange of information through the Levels
Level III (4 Standards)
Utilize technology to educate providers on immunization issues and strategies for improving the delivery of immunization and other preventive services
Develop and disseminate an annual summary report on immunization quality improvement activities
Mentor other programs
Document methods used to exchange information for each age group assessed if different methods are used for age groups
Level III Standards for Exchange of Information focus on allowing grantees to creatively determine how best to exchange information on improving immunization coverage levels at the provider.
The development of annual summary report on immunization related quality improvement activities.
Level III standards promote grantees to share their success by becoming an immunization champion to other grantees, health care organizations or NIP through the CPAWG committee.
Finally, if the methods to exchange information differ by age group within your program then provide protocols specific for each age group.

19. Program Evaluation through the Levels
Level I (4 Standards)
Collect data in formalized electronic data base and submit required information to CDC in a timely manner
Develop and implement a process evaluation of the AFIX program
Level II (2 Standards)
Develop methods to document and track interventions and outcomes
Annually review the effectiveness of office based interventions
Change in coverage levels
Perceived ease of implementation by office
Acceptance of intervention
Resources required to implement
Program Evaluation is an important component of any program. The Level I AFIX Standards for Program Evaluation focus on collect data required by NIP and submitting the data to CDC by the due date.
Level I also requires programs to develop and implement a process evaluation of the AFIX program.
Level II builds on level I and other related Component standards to evaluate the effectiveness of office based interventions

20. Program Evaluation through the Levels
Level III (3 Standards)
Evaluate the impact of immunization champion activities on improving coverage levels
Implement written research and evaluation strategic plans that include developing studies focusing the AFIX strategy. Include timelines for each study. Document a periodic review and update of the strategic plan.
Use research results to make programmatic changes
Level III Standards focus on promotion of research related to the AFIX program and making programmatic changes based on the results.
Evaluation of the impact of an active immunization champion on coverage levels.

21. What else is in the Standards Document?
Self Assessment Worksheets for all components and standards
Assists programs to determine their AFIX program’s status
Resource materials

22. Tackling the Standards
Are you confused and don’t know where to start with the standards?
Start with one or two components that have written protocols in place. For example, job descriptions are a start for Program Operations

23. Tackling the Standards
Prioritize components and standards to help build your AFIX program

24. Technical Assistance How to request technical assistance Contact:
Nancy Fenlon
Amy Kirsch

25. Summary
Standards were developed to provide a framework for planning and implementing a standardized AFIX program
Grantees are not expected to achieve completion of an entire level immediately
Grantees are expected to develop a plan to achieve the Level I Standards
It will take steady work to achieve the Standards
Technical assistance is available for all Levels