Delivering quality immunization services is more complex now than it has been since people had to hold the cow steady to scrape off some pox. It requires time and energy, precious resources mat we all try to conserve. To make it more difficult, our motivation may not be strong because our patients' parents probably do not know what is considered quality immunization practice.
For example, parents may not know that their 18 month old should have received a diphtheria and tetanus toxoids and acellular pertussis (DTaP) booster, may not realize that receiving a Vaccine Information Statement (VIS) before vaccination is a right, and may not be aware that their children - even adolescents - are eligible for free vaccination through the federal Vaccines for Children (VFC) program.
The Standards for Pediatric Immunization Practices1 were written when the men now at the helm had all of their hair. Nonetheless, these standards still ring remarkably true. Unfortunately, the committee that devised them was composed entirely of "splitters" - not a "lumper" among them - so they came up with 18 standards. It is my hypothesis that U.S. immunization rates lag behind those in other developed countries because no modern U.S. health care provider can remember the 18 standards, nor remain still long enough to read them all in one sitting. (Or it may be the absence of universal health insurance for children.) Thus, I have lumped them down to a list of 5 immunization delivery service "commandments."
1. Store and handle vaccines with the care you would give a tyrannosaurus rex egg.
2. Administer vaccines with all the knowledge and skill you would want from a person pushing a needle into you.
3. Optimize communication about vaccine risks and benefits among experts, health care providers, and families.
4. By all means optimize coverage with all recommended vaccines in all age groups, including rninimizing costs to families, but avoid wasting vaccine.
5. Do what it takes to improve the quality of your immunization services continuously.
For the splitters among us, the table lists all 18 standards, grouped under these categories.
Perhaps you are a child of the information age and want upto-the-minute messages. After all, the Standards for Pediatric Immunization Practices were published almost a decade ago. For those in this camp, I will share the unofficial top 5 messages for health care providers in 2001 from the Immunization Services Division of the National Immunization Program (L. Rodewald, MD, personal communication, March 15, 2001). You will see that they reflect the time-honored standards.
1. Offer all vaccines recommended by the Advisory Committee on Immunization Practices, including new vaccines, to your patients.
2. If you operate a teen center, a sexually transmitted disease clinic, a school clinic, a family planning clinic, a juvenile corrections clinic, or another setting in which children for whom hepatitis B vaccine is recommended are seen, offer the benefit of vaccination to your patients and join the VFC program.
3. Remember that influenza kills more children than do all other vaccine-preventable diseases combined. Offer the benefit of influenza vaccine to patients for whom it is recommended.
4. Keep track of the patients in your practice who are in need of vaccination and use recall and reminder systems to optimize coverage.
5. Question whether your office is doing as well as it can at implementing the Standards for Pediatric Immunization Practices by having a VFC site visit with a coverage assessment.
The 18 Standards for Pediatric Immunization Practices by Category
WHY YOU WANT A VFC SITE VISIT
What is a VFC site visit? It is a new and exciting step in the relationship between the private and the public sectors. For years in the United States, the relationship between these groups was a lot like the relationship between boys and girls in the third grade - each was aware that the other existed, but neither was sure what for.
Currently, things are changing. The private sector clearly is where the patients are; far fewer children are immunized in public health clinics than in comprehensive primary care settings. Public health personnel can now turn their attention to providing support to private sector physicians who provide immunizations.
Public health personnel offer a host of educational opportunities, including web-based training, live satellite broadcasts, and even good old-fashioned textbooks on immunization. They can share excellent, low-cost or no-cost education materials for parents. But the most important form of support they have to offer is VFC, the federal program that covers vaccine costs for eligible children from birth through 18 years of age.
Free vaccine does a lot to maximize coverage, but health care providers enrolled in the VFC program can also receive a VFC site visit in many states. A state or local immunization specialist will come to the practice to help the office manager and staff with issues of immunization quality. For example, he or she can provide an in-service session on storing and handling vaccine properly, share the most recent VISs, provide a sample of standing orders for vaccination, and, in some states, even help with recall and reminder systems. The specialist can assess what the practice's immunization rates actually are and give the office team feedback on how well they are doing - feedback that is essential to success.
WHAT THESE IMMUNIZATION ISSUES OFFER
This issue and the July issue of Pediatric Annals will help guide pediatricians and their office teams in their efforts to optimize the quality of immunization delivery services.
In this issue, we concentrate on vaccine storage and handling and the optimization of coverage levels in all pediatric age groups for all recommended vaccines. This issue of Pediatric Anmls will remind pediatricians that the recommendations include vaccination with some new vaccines (eg, pneumococcal conjugate) and some vaccines that are not as new but that are underutilized (eg, varicella and influenza). It will also update pediatricians on meningococcal disease and the option for prevention.
In the July issue, we will focus on vaccine administration, safety, and communication of benefits and risks. Throughout both issues, we will emphasize ways to improve immunization practices through education and collaboration between the private and the public sectors.
Finally, by way of confessions, I will admit mat the phrase "continuous quality improvement" gives me urticaria. I am deeply challenged by the morass of demands life makes on me, so, frankly, I am not up to "continuous quality improvement" in all areas. I am doing well if I can achieve a sort of now-and-again quality improvement in most domains and truly continuous improvement in one, maybe two. For the rest, I must rely on the commitment, intelligence, and kindness of others. This is why I believe in immunization champions.
Every office should have one - a person who takes on immunization as his or her passionate mission and does whatever it takes to get the systems in place to ensure quality immunization services. Of course, the immunization champion cannot succeed alone; absolutely every member of the office team must be involved. The cleaning personnel who leave the refrigerator that contains the vaccines plugged in all the time, the provider who talks with the mother requesting separate measles, mumps, and rubella vaccines, and the receptionist who calls a family to reschedule the appointment they missed all play a role in immunization quality. But the office needs an immunization champion to coordinate their efforts, to keep up with and transmit the important immunization news, and to make sure the team is attaining its goals.
Quality services may, on occasion, occur in a sporadic way. Without training or protocols, a dedicated and creative worker - at any given moment - may find a way to deliver the right thing at the right time with a smile. Similarly, I recall from physics class that, because the molecules of my body and the molecules of the door are mostly open space, there is some small possibility that I could walk through a door without opening it. But all of the odds are against both of mese. Almost always, quality must be built in from the beginning with carefully crafted protocols and training on these protocols. It sounds so corny, so trite, so administrative, but I have been convinced of it. Often, the only way to do something common properly is through beautiful routines. (I see this most frequently in the emergency department, where we boggle the care of the VIP's child because we fall all over ourselves trying to do things in uncustomarily efficient ways.)
Vince Lombardi said, "Practice does not make perfect. Only perfect practice makes perfect." The office immunization champion needs to understand immunization and the office to perfect the immunization practice. This perfection will require a systems approach.
I hope these issues will offer something for everyone in your office. More importantly, I hope that they will inspire your team to identify an immunization champion who will read both issues from cover to cover and implement what he or she learns.
1. Centers for Disease Control and Prevention. Standards for pediatric immunization practices. MMWR. 1993;42(RR05):001.
The 18 Standards for Pediatric Immunization Practices by Category