Almanac Highlights Series: Boosting Immunization Performance for High-Risk Patients in an Academic Safety-Net Hospital

By Lauren C. Betancourt, MPH1, Julie Boyle, RN2, Nancy Figueiredo, RN2, Briana McNeill, BS2, Jason Reich, MD2, Michael R York, MD2

  • 1Boston University School of Medicine
  • 2Boston Medical Center

Innovation in CME/CE happens every day within large and small projects. This series aims to highlight education that is creatives, interesting, different, entertaining and overall noteworthy. In each installment, we will showcase a program that that demonstrated that education can be facilitated in different ways.

Project Summary

A rheumatology clinic based in an urban safety-net hospital demonstrated historically low performance in vaccinating its immunosuppressed patient population against pneumococcal disease. In order to mitigate patients’ disproportionately high risk of infection, our quality improvement (QI) team was configured to improve the clinic’s immunization performance. Our team, consisting of clinical specialists and administrative CME departmental stakeholders, used the Institute for Healthcare Improvement’s Model for Improvement to shepherd the effort.

Past performance data revealed that when presenting in clinic, only 2 percent of eligible patients were successfully immunized against pneumococcal pneumonia. Based on the alarming gap in performance, the initial aim of the initiative was to vaccinate 60 percent of immunosuppressed patients eligible to receive a pneumococcal vaccine in four months’ time. For the department of rheumatology, this meant vaccinating 75 patients per week with nursing resources1 amounting to only 1.5 FTEs. Despite ample knowledge of the challenges at hand, the team decided to adapt an intervention that was efficacious in an Inflammatory Bowel Disease (IBD) Clinic with a similar patient demographic within our same safety-net hospital.


This intervention employed worksheets for providers that prompted them to screen patients for vaccination eligibility. When implemented in the rheumatology clinic, it failed to achieve success for three reasons.

  • There was no standardized method of communicating the need for vaccinations to nurses in real-time.
  • Providers quickly became overwhelmed with the volume of eligible patients and feared they wouldn’t be able to continue to accommodate vaccination conversations at the current frequency.
  • Nursing coverage was such that, when the time came for an eligible patient to be vaccinated, nursing staff was often preoccupied.


After a department-wide discussion and review of qualitative and quantitative data, the team narrowed the scope of the aim to vaccinate 60 percent of patients eligible to receive a pneumococcal vaccine prior to beginning treatment on a biologic medication2. Based on the learnings from PDSA 1, our team formatted a standard method of communicating vaccination orders that was embedded within a pre-existing communication route for obtaining prior authorizations3 (PAs) for patients starting on new biologic medication. Our team acquired a new stakeholder, a pharmacy patient liaison4 that assisted in navigating the PA process to ensure that the right information was being employed at the right time to the right stakeholders.

Patients starting treatment presented a strategic advantage as the population of interest. Before starting treatment, they were required to schedule a follow-up appointment and meet with a nurse for a demonstration on how to properly self-inject. At this point, nurses could plan to initiate a conversation about vaccinations without having to be available to do so on a just-in-time basis.

“Since patients are required to come to clinic for teaching before they can get their new medication, it makes it easier for us to track patients and guarantee they get vaccinated.” —Briana McNiell, Pharmacy Patient Liaison, Boston Medical Center


The team was able to boost the immunization rate from 2-27 percent in three months. Eleven out of 15 providers and nurses effectively communicated vaccine eligibility in using the standardized format.

Immunization Project.png

*Number under percentage represents # of eligible patients

*This chart represents data derived from the EHR through random sample audit


There were several important considerations derived from experiential learning that strongly influenced the team’s ability to improve. The effectiveness of the interventions relied heavily on context, resources and infrastructure. A series of reminders were placed in patient rooms to supplement awareness and reinforce the standard approach for providers communicating orders for vaccinations. We presume that these reminders were associated with the improved performance. The improvement was heavily attributable to the undivided engagement of the nursing staff, without which improvement would not have been realized. The first PDSA cycle failure highlighted a resounding theme in QI practice; despite similarities in context and patient population, interventions that render success in one local environment are not always successful in another.


Because the results were derived from randomized audits, providers that were not consistently on service were difficult to capture in our audits. We estimate that the standardized communication strategy was used by a larger number of providers.

Operational Definitions

1Nursing resources as they pertain to vaccinations are a primary determinant of immunization performance. For clinics without dedicated pharmacists, nurses are often the sole responsible party for administering vaccines.

2 Biologic medications consist of engineered proteins derived from human genes. Biologics are able to inhibit elements of the immune system that fuel inflammation.

3 Prior authorizations are used by health insurance companies to determine if they will cover a prescribed procedure, service, or medication before it is administered.

4Pharmacy Patient Liaisons are responsible for coordinating patient, provider, insurance and pharmacy concerns related to medication coverage and cost.

Note: This activity was funded by an independent medical education grant from Merck.

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