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Running head: IMPROVING STAFF KNOWLEDGE AND SKILLS ON IMMUNIZATION

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Organizational Assessment:

Improving Staff Knowledge and Skills on Immunization

at Skagit Regional Clinics

N. Tabara Khan, RN, Josefina Turnek, RN, Kathryn Lewandowsky, RN

Western Washington University RN-to-BSN Program

NURS 422 Organizational Change for Quality and Safety in Healthcare

December 2, 2016

IMPROVING STAFF KNOWLEDGE AND SKILLS ON IMMUNIZATION

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Introduction

Immunization prevents between two to three million deaths annually in all age groups

from diphtheria, tetanus, pertussis, and measles (World Health Organization, [WHO], n.d.). It

was through immunizations that smallpox was eradicated. The WHO estimates that one in four

children are not immunized and about three million people die annually from vaccine

preventable diseases (Cameron, 2009). Recommendations and guidelines are provided by the

Centers for Disease Control and Prevention [CDC] according to the different age groups

(Immunization Schedules, n.d.), however the CDC does not set the immunization requirement

for schools and childcare centers in every state (State Vaccination Requirements, n.d.). The

immunization requirements and immunization schedules are based on the recommendations of

the Advisory Committee on Immunization Practices (ACIP) who “provide advice and guidance

to the Director of the CDC regarding use of vaccines and related agents for effective control of

vaccine-preventable diseases in the civilian population of the United States” (ACIP Charter,

2016, p.1).

The vaccine coordinator at Skagit Regional Clinic (SRC) has given our practice

experience group the privilege of restructuring the clinic’s immunization class. Our group is

revamping this class in order to improve new employee’s ability to learn the materials necessary

in providing safe, effective immunizations to their clients while avoiding unnecessary

complications. In restructuring this class, our goal is to reduce redundancies, restructure class

contents in a more logical order and incorporate web links to facility system wide immunization

policies and protocols along with also national websites that provide evidence-based

immunization resources. We also hope to reduce paper consumption by the system and improve

employee’s ability to locate immunization resources in their day-to-day workflow. We felt it is


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important to include web links for additional educational materials necessary to properly store

and administer immunizations according to the CDC guidelines and also Washington State

Schools guidelines for school entry requirement (School and Child Care Immunizations, n.d.). It

will also touch the SRC’s NextGen current Electronic Medical Record (EMR) documentation

system so that all new SRC employees will be confident in how to properly document all of the

required information within their EMR.

Immunization is the most successful and cost-effective public health intervention

throughout the world. It has been proven to be the most successful prevention against vaccine

preventable infectious diseases (Immunization & Child Profile Office, n.d.) especially in children

(WHO, n.d.). Due to the fact that their immune systems are still in the process of developing, it is

crucial that this vulnerable group get immunized against vaccine preventable diseases. The

Washington State Schools have clear requirements that all children according to age have

received a series of vaccinations against infectious diseases prior to school entry (School and

Child Care Immunization, n.d.). Unfortunately, not all children have received their required

immunizations. Some children are exempt for several reasons such as medical, religious or

philosophical (State Vaccination Requirements, n.d.), while others may not have received the

immunizations as correctly outlined in the Washington Department of Health [WA. DOH] and

CDC guidelines. These children who are not immunized are at risk for exposure to vaccine

preventable infectious diseases. They then may also put other vulnerable people in the

community at risk for acquiring vaccine preventable infectious diseases including the very

young, the very old, and those who have chronic conditions or are immunocompromised.


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Change Theory

Change sometimes is necessary for any organization to improve or adopt new or better

ways of doing things. Change can be challenging and may make some people feel uncomfortable

or uneasy. On the other hand, some people may see change as an opportunity for improvement or

as a sign of hope. The nursing profession always strives for excellence to provide cost effective

patient care based on evidence and because of that, quality indicators have been chosen to

adequately assess quality improvement. In order to make the necessary changes, an organization

needs to have a solid plan. Several theorists have attempted to explain the proper way of

approaching change and one of them is Kurt Lewin, who was a physicist and a social scientist.

His most influential theory is what is known as the “Lewin’s Change Theory” which he

developed in the 1940’s and is still being used today by many businesses and organizations. It is

a three-staged model of change known as the unfreezing-change-refreeze model (Mind Tools

Editorial Team, n.d.). This model promotes letting go of old, formed, counterproductive habits,

replacing them with new productive practices and then making these new productive practices

the new normal or the standard way of doing things.

The first stage is the “unfreezing stage” which Lewin called the “quasi-stationary

equilibria.” This stage uses a force field analysis to assess the driving and restraining forces in

order to reach the desired goal or outcome. The second stage, which is the “change” stage, is for

individuals to adapt the new ways of doing things and work within the change. The model is

completed through the third stage, or the “refreezing” stage. It is completed when the new way

of doing things is now the new “norm” or standard way of doing things (Sare & Ogilvie, 2010).


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Lewin’s Change Theory addresses what we are trying to accomplish in restructuring the

immunization class in Skagit Regional Clinics. We have several goals to accomplish in this

project. In the unfreezing stage, we want the new employees to become confident in their skills

in order to give vaccinations safely by following evidence-based policies and procedures,

understand the proper procedures of mixing vaccines as well as proper vaccine storage and

where to locate the web links for additional educational materials in SRC’s intranet. Employees

also need to be clear which vaccine supplies are for private pay clients and which are for public

pay clients and the need for them to be kept separate in order to satisfy the CDC and Washington

State Vaccine for Children guidelines (VFC, n.d.; Vaccines for Children Program, n.d.). In the

“change” stage, employees will have the knowledge, skills and confidence in the proper

administration of vaccine and understand how and where they are stored and be able to

document properly in the SRC’s EMR, all the pertinent information required.

Our ultimate goal is to “refreeze” all of SRC’s vaccinators to be all skilled, confident,

competent and to document 100% of all the pertinent information required in their EMR.

Hopefully with the implementation of this newly restructured immunization class, we can begin

to unfreeze the beliefs and attitudes of new employees as well as the current employees. With the

reinforcement of annual competencies for all vaccinators, the expectation will ultimately

“change” their view of the importance of their own immunization practices and having the

information in an easily retrievable format will help to “refreeze” the facility guidelines and

practices moving them towards the new “norm”.

In this project, we also proposed a PDSA cycle with the goal of reducing the number of

errors in documentation and administration of vaccines administered within the Skagit Regional


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Clinic system by 90%. Since our time is limited, this project will need to be implemented after

we have completed our clinical experience this quarter. Hopefully, the facility and/or next cohort

will be able to gather data and evaluate the effectiveness of this proposed PDSA and make the

necessary changes to help reach our proposed goals (See Appendix B).

Force Field Analysis

The force field analysis is a valuable tool that we applied in our organization change

project. This model was developed by Kurt Lewin in the early 20th century for managing change

in the workplace. This is a tool that is widely used in the 21st century as one of the most

effective models for organizational change and business improvement (Change Management

Consultant, 2016) and assesses the organization’s driving forces and restraining forces to aid the

process of changing an organization’s current equilibrium and status quo. Our expectation is for

SRC to achieve an organizational culture of immunization competency by improving staff

education on vaccine administration and documentation.

For SRC to adopt the necessary changes in their organization, we first identified some of

the challenges the organization faces in the form of forces that may be restraining change. There

is inadequate knowledge by staff members about Vaccine for Children (VFC) that are being

offered for children from birth to 18 years by the state and this needs to be clarified through staff

education. As a driving force, the immunization class will help staff and new employees to be

educated on the VFC program. Another restraining force impeding the organization to adopt a

culture of immunization is incomplete documentation of vaccine administration. Per our mentor,

missing documentation of vaccine lot numbers was noted to be a problem. Due to the upcoming

adoption of EPIC software within the organization, the Information Technology (IT) department


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is not able to make hard stop changes to the current EMR. Staff education and reinforcement on

the importance of precise documentation of vaccine administration will increase awareness and

compliance (See Appendix C).

Due to inadequate staff knowledge on CDC and WA. DOH immunization requirements

and their busy work schedule, SRC staff does not have adequate time to document all the

pertinent vaccine information in NextGen. This is a restraining force that needs to be addressed.

In alignment with the CDC and WA. DOH, educational materials and resources in the

immunization class will help clarify and educate staff about vaccine requirements and direct staff

to access resources more easily in their day-to-day work environment.

The organization’s participation in AFIX is among the driving forces. AFIX is defined as:

“Assessment of the immunization coverage of public and private providers, Feedback of

diagnostic information to improve service delivery, Incentives to motivate providers to change

immunization practices or recognition of improved or high performance, and eXchange.” (CDC,

2015, p. 34) and is a program offered by the CDC. SRC participation in the AFIX program

increases the driving forces in adopting a culture of immunization in the organization by

increasing reimbursement based on the increases in documented completed immunizations

(CDC, 2015). This program is a positive force to encourage staff to properly enter the

appropriate vaccination dates and AFIX data. Improved documentation will lead to improved

reimbursement rates that will ultimately assist the organization in remaining fiscally responsible.

Recommendations

The revamping of the SRC Vaccine and Immunization class will propel the organization

toward positive change in the form of adopting a culture of immunization. This class will educate


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SRC staff about the differences between states supplied vaccines and private pay vaccines. Staff

will be educated about the VFC program, how to locate VFC supplies and who are eligible for

the VFC program (VFC, n.d.; Vaccines for Children Program, n.d.). Through this education

class staff will become competent in appropriately identifying VFC supplies. Overall, this will

prepare SRC staff to understand CDC and WA. DOH guidelines regarding vaccine storage and

handling and administration and increase staff knowledge in locating resources for vaccines and

immunizations in their clinic.

The vaccine administration documentation is very important in order for SRC to stay in

compliance with CDC and WA. DOH guidelines. Our mentor, Kirty M., RN stated that proper

documentation allows for the information to cross over to the Washington Immunization

Information System (WAIIS) which will allow the WA. DOH the ability to assess more

accurately the immunization rates in our community. This will be reflected in improved

vaccination rates for all age groups that are of concern and are currently being monitored and

assessed through the Skagit Community Health Assessment Survey Annual Report (2015).

As recommended by the CDC, knowledgeable staff is the key to understanding and

preventing vaccine administration errors. As part of SRC’s policy and procedures, the CDC

recommends staff training and education on vaccine storage and handling and proper

administration to be a part of new employee orientation and annual trainings for all staff

involved in vaccine administration. They also encourage staff to be informed whenever

recommendations are updated and when new vaccines are added (Weaver, 2015). To prevent

errors on administration of a vaccine without the proper diluent, the CDC recommends to keep

vaccines and diluents in original packaging with lids on to maintain temperature and protect from


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light. Other recommendations include stacking each type of vaccine with the required diluent in

rows 2-3 inches apart and the use of labels with vaccine type, indications or color coding to

prevent errors.

An immunization champion can help overcome the barrier of staff resistance to change

and/or feelings of intimidation. Per our mentor, staff may feel intimidated or embarrassed to ask

for help on proper vaccine administration. Also regarding the differences between federal and

state immunization requirements due to the lack of staff not administering vaccine on a regular

basis. Evidence-based strategies recommend bringing resources and information to staff

regularly, tracking and reporting on progress towards goals, offering coaching to staff and

reinforcement for employees on how their role supports immunization and vaccination in the

organization (Oregon Health Authority, n.d). If adopted, these recommendations can help the

organization overcome restraining forces and smooth the transition of change.

Conclusion

Many studies show the effectiveness of immunization and the many numbers of lives

saved from preventable diseases in all ages, and yet one in every four children is not immunized,

leading to almost three million unnecessary deaths every year. As healthcare workers, it is our

obligation to champion for the lives of the people we serve and provide them with the highest

quality health care available. We can start that in the community we serve by understanding the

most effective ways to administer these immunizations against vaccine preventable diseases. As

employees of SRC, education and knowledge are the fundamental keys to success. Being open to

new changes is a start, and adopting recommended evidence-based practices on vaccine storage,


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handling and administration, will lead to confident and competent staff to serve SRC’s

community.


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References

ACIP | Home | Advisory committee on immunization practices | CDC. (n.d.). Retrieved

November 2016, from https://www.cdc.gov/vaccines/acip/

Cameron, N. (2009). Why do we immunize children? Professional Nursing Today, 13(3), 36–

41.

Center for Disease Control and Prevention (2015). Immunization strategies for healthcare

practices and providers. Retrieved from

https://www.cdc.gov/vaccines/pubs/pinkbook/downloads/strat.pdfhttps://www.cdc.gov/vac

cines/pubs/pinkbook/downloads/strat.pdf

Change Management Consultant: Force field analysis free step-by-step guide to Kurt Lewin

Force Field. Retrieved November 7, 2016, from http://www.change-management-

consultant.com/force-field-analysis.html

Immunization & Child Profile Office, Washington State Department of Health. (n.d.).

Retrieved October 18, 2016, from

http://www.doh.wa.gov/ForPublicHealthandHealthcareProviders/PublicHealthSystem

ResourcesandServices/Immunization

Immunization Schedules | CDC. (n.d.). Retrieved October 30, 2016, from

https://www.cdc.gov/vaccines/schedules/

Lewin’s Change Management Model: Understanding the three stages of change (n.d.). Retrieved

October 31, 2016, from http://www.mindtools.com/pages/article/newPPM_94.htm

Oregon Health Authority (n.d). Evidence-based strategies for improving childhood immunization

rates: A guide for ccos. Retrieved from

https://www.oregon.gov/oha/analytics/CCOData/Childhood%20Immunizations%20

https://www.cdc.gov/vaccines/pubs/pinkbook/downloads/strat.pdf



http://www.doh.wa.gov/ForPublicHealthandHealthcareProviders/PublicHealthSystemResourcesa


https://www.oregon.gov/oha/analytics/CCOData/Childhood%20Immunizations%20Resource%20Guide.pdf


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Resource%20Guide.pdfhttps://www.oregon.gov/oha/analytics/CCOData/Childhood

Immunizations Resource Guide.pdf

Sare, M., and Ogilvie, L. (2010). Strategic planning for nurses: Change management in health

care. Burlington, MA: Jones and Bartlett learning. 171-194

State Vaccination Requirements | CDC. (n.d.). Retrieved October 19, 2016, from

http://www.cdc.gov/vaccines/imz-managers/laws/state-reqs.html

School and Child Care Immunization: Washington State Department of Health. (n.d.). Retrieved

October 13, 2016, from

http://www.doh.wa.gov/CommunityandEnvironment/Schools/Immunization

Vaccines for Children Program, Washington State Department of Health. (n.d.). Retrieved

November 30, 2016, from

http://www.doh.wa.gov/ForPublicHealthandHealthcareProviders/PublicHealthSystem

ResourcesandServices/Immunization/VaccinesforChildren

VFC | Home | Vaccines for Children Program | CDC. (n.d.). Retrieved November 29, 2016, from

http://www.cdc.gov/vaccines/programs/vfc/index.html

Weaver, D. L. (2015). Vaccine storage and handling and administration. CDC. Retrieved from

https://www2.cdc.gov/vaccines/ed/epvreg/Downloads/EPV4.pdf

WHO | 10 facts on immunization. (n.d.). Retrieved October 20, 2016, from

http://www.who.int/features/factfiles/immunization/en/




http://www.cdc.gov/vaccines/imz-managers/laws/state-reqs.html

http://www.doh.wa.gov/CommunityandEnvironment/Schools/Immunization




https://www2.cdc.gov/vaccines/ed/epvreg/Downloads/EPV4.pdf


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Appendix A

Vaccine and Immunization Class: Education Logic Model

Statement of Need: Improving Staff Knowledge and Skills on Immunization

Resources/inputs Activities Outputs Outcomes Impact

In order to

accomplish our

set of activities,

we will need the

following:

In order to

address our

problem or

asset, we will

accomplish the

following

activities:

We expect that

once

accomplished

these activities

will produce the

following

evidence or

service delivery:

We expect that if

accomplished

these activities will

lead to the

following changes

in 1-3 then 4-6

years:

We expect that if

accomplished

these activities

will lead to the

following

changes in 7-10

years:

Skagit Regional

Clinic Kirty Morse,

Vaccine

coordinator

Educate new

employees in

best practices of

giving

immunization

Initial injection

and vaccination

administration

program during

New Employee

Orientation

Well informed,

knowledgeable,

and confident

vaccinators

Annual

immunization

competency for

new and current

employees who

administer

injections and

vaccinations

Educational

materials and web

links for

immunization

class

Have new

employees

access

computers to

navigate the

web links for

immunization

class/material

New employees

will know where

to find the web

links for

additional

resources

necessary for

proper

immunization

Employees are

knowledgeable

with the supplied

web links and able

to navigate them

easily

Employees are

confident at

locating

immunization

procedures and

safety

information on

hospital intranet.

Skagit Regional

Clinic

Next-gen

computer charting

program

Teach new

employees how

to correctly

document in

next-gen

New employee

will document in

Next-gen

properly.

New employee

documentation in

Next-gen will

become a routine

skill and will not

miss documenting

vaccine

administration

accurately

100%

documentation

compliance


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Available Vaccine

tool kit for new employee

New employees

to practice

drawing up

diluents and

vaccine from

vials

New employees

will be confident

in properly

preparing

vaccines

Immunizations

will be given with

minimal risk of

complications

Rates of

childhood

immunizations in

our community

of interest will be

at or above the

national average

Organization

versus State

Supplied vaccines

Employees

educated about

the differences

between the

organization

supplied versus

State supplied

vaccines

Employees will

know where

public pay and

private pay

patient’s vaccines

are located or

stored

Employees will

pull the right

vaccines for the

right eligible

patient

State supplied

childhood

vaccines will

remain separate

from privately

provided

vaccines

Skilled,

knowledgeable,

well-trained

vaccinators

Preceptor for

new employees

at SRC

Confident and

knowledgeable

new employee

who is efficient

and caring with

giving

vaccination

Patients will feel at

ease knowing that

vaccinators are

confident in giving

immunizations

Improved

immunization

rates in Skagit

County residents


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Appendix B

PROPOSED PDSA CYCLE

The aim of our project this quarter is to reduce the number of errors in documentation and

administration of vaccines administered within the Skagit Valley Regional Clinic system by

90%. This is a project that will need to be implemented after we have completed our clinical

experience this quarter. Our PDSA recommendations for the facility and/or future Western

Washington University cohorts are documented below.

Plan- To revamp the New Employee Orientation Injections and Immunizations class. Do---- Reviewed class contents, reorganized into more logical sequences, removed

redundancies and made review and access easily available on Skagit Valley Regional Clinic Intranet. Study- Collect data after administering class contents to 4 rounds of new employees

on rate of documentation errors per 1000 patient encounters in Skagit

Valley Regional Clinics. Act--- We recommend evaluation of results after 120 days of implementation to determine effectiveness of changes to program on impacting errors in documentation and administration of vaccinations at Skagit Valley Regional Clinics.


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Appendix C

Force Field Analysis


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Appendix D

Revamping Skagit Regional Clinic Vaccine and Immunization Class


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