INFLUENZA COMPLIANCE

Performance Improvement Project: Influenza Compliance

Rachel Corbin
State University of New York Polytechnic Institute

INFLUENZA COMPLIANCE

While collaborating with my preceptor (provider B) and he was asked about his thoughts
on a topic for a performance improvement plan (PIP) he responded: thats the most boring topic
I can think of and I usually avoid it as much as possible. I was a bit taken back by his statement
and I asked myself how could a topic of performance improvement provoke such a negative
response from him? Then, it dawned on me: performance improvement is emotionally charged
topic. We would be discussing a topic on his performance with his patients so this would force
him to think about topics he normally would not want to think about.
In general, we as human beings, do not like to be criticized or told our performance is
not up to standards or could be improved. The fact I am a Nurse Practitioner student" who
would be evaluating and critiquing his performance to conclude a plan to improve his
performance in the area of interest didn't catch his attention.
After our short conversation about the PIP, I chose to meet with the office manager, Mrs. B and
address a topic of concern that was disabling the office from providing safe quality service that is
effective and patient-centered. Mrs. B. stated that the office is committed to the ongoing
improvement of the quality of care their patients receive so she would collaborate with me on
any necessary topic to help improve the care the office can provide.
We chose to address provider Bs patients compliance with the Centers of Disease
Control recommendations regarding the influenza immunization. We chose this topic because of
the health promotion benefits that come along with receiving this vaccination. Patients who are
vaccinated against influenza have reduced flu illnesses, missed work days, school and even
reduced doctors office visits which help with office congestion (Santibanez, Mootrey, Euler, &
Janssen, 2010).

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Evidence supports that Influenza is a serious disease that can lead to hospitalization and in the
high-risk population patient and they can even die from the disease. Not every flu season is the
same and it can infect healthy people who then can spread it to other healthy people who then
can spread it to the high-risk population.
Seasonal influenza contributes to substantial morbidity and mortality each year in the
United States (Baxter, Lee, & Fireman, 2010). According to the Centers for disease control,
Flu season in the United States can begin as early as October and last as late as May. During
this time, flu viruses are circulating at higher levels in the United States population.
An annual seasonal flu vaccine is the best way to reduce the chances that you will get
seasonal flu and spread it to others. CDC recommends a yearly flu vaccine for everyone 6
months of age and older as the first and most important step in protecting against this serious
disease. People should begin getting vaccinated soon after flu vaccine becomes available, if
possible by October, to ensure that as many people as possible are protected before flu season
begins. However, as long as flu viruses are circulating in the community, its not too late to get
vaccinated (CDC, 2016).
When more people get vaccinated against the flu, less flu can spread through that
community (Santibanez, Mootrey, Euler & Janssen, 2010). Over a period of 31 seasons between
1976 and 2007, estimates of flu-associated deaths in the United States range from a low of about
3,000 to a high of about 49,000 people (Baxter et al, 2010). During recent flu seasons, between
80% and 90% of flu-related deaths have occurred in people 65 years and older (Baxter et al,
2010).
This primary care office is located in a small town that serves a very low socioeconomic
community. It has been well established in the literature that lower socioeconomic status is

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related to poorer health outcomes as measured by morbidity rates for most diseases, mortality
rates, and measures of general well-being (Greene, & Murdock, 2013). Therefore, the patients
with poor health and increased risk factors for influenza are among this small community. These
patients can benefit from receiving the influenza vaccination ever single year.
The office is the one of two primary care offices in the town. It sometimes can take
months to get an appointment to established patients and they are not currently accepting any
new patients because the office is too busy. The CDC reported in the 2014-2015 influenza season
that there were approximately 19 million influenza-associated medical visits (National Vaccine
Advisory Committee, 2013).
The CDC finds that vaccinations can reduce medical costs and indirect costs such as
those from lost work productivity. The National Vaccine Advisory Committee, 2013 reports that
vaccinations could result in 13%44% fewer health-care provider visits, 18%45% fewer lost
workdays, 18%28% fewer days working with reduced effectiveness, and a 25% decrease in
antibiotic use for influenza-like illness. In addition, vaccination may contribute to $60$4,000 in
savings per illness in healthy adults, 65 years of age depending on the cost of vaccination, the
influenza attack rate, and vaccine effectiveness against flu-like illnesses (National Vaccine
Advisory Committee, 2013).
This office is very busy and could possibly decrease their number of sick calls if
patients were vaccinated against influenza. Thus, decreasing their daily patient load and allowing
for more patients to join the practice. Currently, the practice has roughly 5,000 patients and 1000
of them being provider Bs patients. The office maintains a vaccination data log that is required
by the public health department. In the last 12 months, only 100 influenza vaccinations were

INFLUENZA COMPLIANCE

given to provider Bs patients. Thus, indicating a concern for provider Bs 10% compliance with
the CDCs recommendations influenza vaccination rate.
After reviewing the log with the office manager we decided an acceptable level of
compliance would indicate that 90% of high-risk patients within the practice who were offered
the influenza vaccination would be immunized yearly prior to the flu season. This percentage
was determined from provider Bs reported low influenza vaccination administration over the
last 12 months.
A randomized retrospective chart review was completed. We narrowed down the number
of charts by focusing on the previous flu season (October 1, 2014 - March 1, 2015). Because
most healthy people who get the flu have a mild illness and it will not require hospitalization or
significant utilization of medical care we chose to focus on patients with chronic medical
conditions. Out of the 100 patients who received flu shots only, 10 of them were patients with
chronic medical conditions. So, Dr. Qs patients were only 10% compliant with the CDCs
influenza vaccination recommendations. Carefully, and strategically the 10 charts were reviewed
and a spreadsheet created to determine the reasons for the noncompliance.
Once the barriers were identified as potential causes for low vaccination rates, targets
were outlined for the quality improvement project. A comprehensive performance improvement
approach is the most effective strategy for achieving increased influenza vaccination throughout
the entire population of the office but even more complex when targeting the high-risk group of
patients.
Recommendations are often updated by the CDC, so one way the practice can improve is
by providing continuing education to staff can keep staff up to date with the current research.
Providing comprehensive education and training about the risks of influenza and the safety and

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efficacy of influenza vaccine are essential components of a comprehensive approach (Greene &
Murdock, 2013).
The office currently does not flag any charts with patients that are missing flu shots or
any other type of preventive care. If vaccination levels had reached the Healthy People 2020
target of 70%, an additional 5.9 million illnesses, 2.3 million medically attended illnesses, and
42,000 hospitalizations might have been averted (Keith & Sherrod, 2012). Now that it become
evident the office had such low influenza vaccination rates it was a priority to develop a plan to
help the office increase their influenza vaccinated population.
Oneida Health associates is a family practice clinic that cares for a medically underserved
population. That springs issues of low-income and underinsured along with low health literacy. I
developed a plan to boost the percentage of high-risk adult patients aged 65 years and older who
would be vaccinated against influenza to achieve our acceptable level of compliance of 90% by
the end of the 2016/2017 flu season.
My plan included several interventions 1) Patient outreach through letters and phone calls
from the office to inform them of their vaccination status. 2) Modifying how the office identifys
patients who are in office and in need of the vaccination. In order to do this yellow sticker would
be applied charts of those who had not yet received the vaccination and those at high risk. 3)
Modification of immunization tracker on the database of the electronic medical record to allow
bold red alerts to cross the screen when a patient is in need of the vaccination. 4) Incorporating a
new clinical algorithm to be used by provider B to help quickly identify patients who are high
risk and in need of the extended education about the influenza virus. These algorithms would be
placed in all the in the exam rooms for easy access. 5) Meeting with the high-risk patients to help
identify the potential barriers. 6) Creating a patient information sheet about influenza that is

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written to target the offices low health literacy population. This sheet will be hung on the wall in
each exam room. People with limited health literacy often lack knowledge or have
misinformation about the body as well as the nature and causes of disease. Without this
knowledge, they may not understand the relationship between lifestyle factors such as diet and
exercise and various health outcomes (Bayne, 2007).
This project went well overall, however, in my opinion, addressing poor performance is
key to every health care organization. One of the substantial difficulties came with the resistance
of the providers cooperation to address performance issues. I feel like ignoring poor
performance is not only a bad practice, but it can be costly to the office. Allowing poor
performers to go unchecked can diminish the quality of services provided the patients in the
practice and even decrease profits.
If I had to do this project again there are several things I would do differently. The most
important change I would make is to plan ahead and possibly introduce the topic in a more
naturalistic way. This way by setting expectations upfront and viewing performance as a
continuous process there would be more opportunities to address performance issues as they
occur rather than wait for problems to become systemic. Overall I was pleased with the feedback
from Mrs. B and the outcome and performance plan for this office.

References:
Bayne, C. (2007). Technology assessment. Patient information systems: unbiased information is
key. Nursing Management, 28(3), 50-53 3p.

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Baxter, R., Lee, J., & Fireman, B. (2010). Evidence of bias in studies of influenza vaccine effec
tiveness in elderly patients. Journal Of Infectious Diseases, 201(2), 186-189 4p.
Centers for disease control influenza recommendations, 2016; retrieved from CDC.com on
March 6, 2016
Greene, C. A., & Klein Murdock, K. (2013). Multidimensional Control Beliefs, Socioeconomic
Status, and Health. American Journal Of Health Behavior, 37(2), 227-237 11p.
Influenza 2015-2016: Challenges and Recommendations. (2015). American Family Physician,
92(12), 1049-1050 2p.
Influenza Vaccination for the Prevention of Cardiovascular Disease. (2016). American Family
Physician, 93(5), 357-358 2p.
Keith, L. A., & Sherrod, R. A. (2012). Improving Influenza Immunization Rates Through a Spe
cialized Clinic Review. Journal Of Community Health Nursing, 29(3), 133-142
10p.
National Vaccine Advisory Committee. (2013). Strategies to Achieve the Healthy People 2020
Annual Influenza Vaccine Coverage Goal for Health-Care Personnel:
Recommendations

of the National Vaccine Advisory Committee. Public Health

Reports, 128(1), 725

Santibanez, T., Mootrey, G., Euler, G., & Janssen, A. (2010). Behavior and beliefs about influen
za vaccine among adults aged 50-64 years. American Journal Of Health
Behavior, 34(1),

77-89 13p.

Zielinski, A., Borgquist, L., & Halling, A. (2013). Distance to the hospital and socioeconomic
status influence secondary health care use. Scandinavian Journal Of Primary
Health

Care, 31(2), 83-88 6p

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