Achieving Sustainable Increases in Childhood Immunization Rates

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Analyzing and eliminating physical and procedural barriers to immunization allowed this practice to improve its performance.

Fam Pract Manag. 2014 Jul-Aug;21(4):13-17.

Author disclosures: no relevant financial affiliations disclosed.

The degree to which pediatric patients are up-to-date on recommended immunizations is a key quality metric of well-child care – for both the patient and the practice. Inadequate immunization can increase the risk of acquiring serious infectious diseases. Low rates of immunization can also affect pay-for-performance incentives from insurance plans. In addition, if a practice participates in the Vaccines for Children (VFC) program, poor immunization rates can jeopardize its ability to receive federally subsidized vaccines. For each Medicaid-insured child 6 years old or younger in our urban family medicine practice, we receive about $1,400 worth of vaccines through VFC. The loss of this resource would be devastating for both patients and our practice.

For these reasons, and as part of our pursuit of level-3 patient-centered medical home (PCMH) recognition by the National Committee for Quality Assurance, our practice decided to focus on improving well-child care, and specifically on ensuring up-to-date immunizations, which resulted in dramatic increases in our immunization rates. This article describes what we learned in hopes that other practices might replicate our effort and results.

Our approach

The main metric used by our local health department's VFC program is the completion by age 24 months of four vaccinations for DTaP (diphtheria, tetanus, and pertussis), three for polio, one for MMR (measles, mumps, and rubella), three for Hib (Haemophilus influenzae type B), three for Hepatitis B, one for varicella, and four pneumococcal conjugate vaccinations (PCV7), also known as the “4:3:1:3:3:1:4” series. For children 19 to 35 months of age, the national average for completion of this series in 2012 was 68.4 percent.1 At our combined resident/faculty office, the series completion rate was a disappointing 43 percent in 2010. Meanwhile, chart audits by our department of public health also indicated a high rate (36 percent) of “missed opportunities,” or instances when a child came to the office for some other reason and was not offered the vaccines that were due.

Our PCMH working group, composed of attending physicians, nurses, clinic managers, social workers, residents, pharmacy faculty, medical assistants, and secretarial staff, met weekly, participated in a statewide PCMH residency program collaborative, and underwent quality improvement training.2 Our team gained process improvement skills, including measuring clinical performance, performing rapid PDSA (plan-do-study-act) cycles, conducting stakeholder research and root cause analysis, and developing and testing solutions.3,4 These skills were then applied to improving child immunization rates with the help of tools borrowed from the corporate and manufacturing worlds (these tools are described in the next section),3,4 and all potential solutions were methodically tested.5

What we found

The team's analysis revealed that employees throughout our practice were involved in the immunization

About the Author

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Dr. Nguyen is medical director of Penn Family Care in Philadelphia and assistant professor in the Department of Family Medicine and Community Health at the University of Pennsylvania Perelman School of Medicine....

Heather Klusaritz is an instructor at the University of Pennsylvania Perelman School of Medicine and the School of Social Policy & Practice.

Dr. Cronholm is associate professor at the University of Pennsylvania Perelman School of Medicine's Department of Family Medicine and Community Health, associate program director for the family medicine residency program, and codirector of the Mixed Methods Research Lab.

Author disclosures: no relevant financial affiliations disclosed.

The authors wish to acknowledge the efforts of all providers and staff at Penn Family Care, who helped with the implementation of this quality improvement project.



show all references

1. Centers for Disease Control and Prevention (CDC). National, state, and local area vaccination coverage among children aged 19–35 months – United States, 2012. MMWR Morb Mortal Wkly Rep.2013;62(36):733–740....

2. Penn Medicine Leadership Forum – Transitions in care. Penn Medicine website. Accessed April 17, 2014.

3. Esain AE, Williams SJ, Gakhal S, Caley L, Cooke MW. Healthcare quality improvement – policy implications and practicalities. Int J Health Care Qual Assur.2012;25(7):565–581.

4. Schriefer J, Leonard MS. Patient safety and quality improvement: An overview of QI. Pediatr Rev.2012;33(8):353–360.

5. Hirano H. 5 Pillars of the Visual Workplace: The Source-book for 5S Implementation. Portland, OR: Productivity Press; 1995.

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