MINNESOTA IMMUNIZATION INFORMATION CONNECTION
A Guide to AFIX Site Visit Strategies for Quality Improvement
Strategies to Improve the Quality of Immunization Services:
Question
1. Do you have
a reminder/
recall process
in place for
pediatric/
adolescent
patients?
Discussion Points
Client reminder and recall (r/r) interventions involve reminding members of a
clinic’s population that vaccinations are due (reminders) or overdue (recalls).
The Minnesota Immunization Information Connection (MIIC) Client Follow-Up
tool is available for clinics to use for r/r. Its function is to identify patients who
are due or overdue for immunizations and help clinics follow up with them.
Using the Client Follow Up tool is a great method to ensure that r/r can be done
by clinic staff on a routine basis and using a routine process.
The implementation of vaccination r/r systems has potential benefits beyond
improved vaccination coverage rates. Patients of all ages who are due or
overdue for recommended vaccinations also may have fallen behind in health
supervision visits and may experience barriers to health care in general.
Vaccination r/r systems may help identify patients who are at risk for not
receiving comprehensive primary care.
A clinic that is interested in using the MIIC Client Follow-Up tool to do r/r should
contact their region’s MIIC Regional Coordinator. The MIIC Regional
Coordinator can help train clinic staff on the tool and troubleshoot any r/r
issues the clinic may be having.
Clinics should periodically measure the effectiveness of their r/r system to make
sure it is having the desired effect. For example, clinics may choose to monitor
the number of r/r notices sent and the number of patients who schedule
appointments following receipt of an r/r notice, and/or the number of r/r
notices that are returned because they are undeliverable. Clinics can use this
information to tweak their follow-up lists so the r/r project is most effective.
Resources
▪ Client Follow-Up: MIIC User Guidance and Training
Resources
(http://www.health.state.mn.us/divs/idepc/immun
ize/registry/hp/traincfu.html).
▪ MIIC Regions and Regional Coordinators
(www.health.state.mn.us/divs/idepc/immunize/reg
istry/map.html).
▪ Community Preventive Services Task Force’s guide
to Increasing Appropriate Vaccination: Client
Reminder and Recall Systems
(www.thecommunityguide.org/vaccines/clientremi
nder.html).
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A GUIDE TO AFIX SITE VISIT STRATEGIES FOR QUALITY IMPROVEMENT
Question
2. Do you offer
walk-in or
immunization
only visits?
Discussion Points
Walk‐in or immunization‐only visits provide convenient vaccination services
proven to improve access to immunizations. Given busy parent and child
schedules, convenient express services are helpful and appreciated.
Offering appointments in the late afternoon, evening, and on weekends is a
best practice strategy. Also, for families who pay out of pocket for health costs
or who have copay or deductible, immunization‐only appointments typically
result in lower out-of-pocket costs.
The National Vaccine Advisory Committee’s “The Standards for Pediatric and
Adolescent Immunization Practices” supports the need for vaccine‐only
appointments and appointments available at convenient times for the working
parent.
3. Do you
Raising staff awareness of coverage levels confirms efforts that are working and
routinely
points to areas for improvement, such as specific ages and vaccines.
measure your MIIC’s Childhood and Adolescent assessment reports are available to clinics
clinic’s
who wish to measure their immunization rates. These reports clearly show the
pediatric/ado
current levels of coverage by vaccine and by series. The Minnesota average for
lescent
immunization each vaccine is also indicated on the report, as well as the Healthy People 2020
goals for immunization coverage. Clinic staff who wish to run these reports
coverage
levels and
should get in touch with their region’s MIIC Regional Coordinator for training on
share the
this function.
results with
These reports can help clinics identify certain vaccines with lower coverage
your staff?
rates, root causes for missed opportunities, or certain age groups with lower
coverage rates than others. Once clinics are aware of gaps in immunization
coverage, staff can plan quality improvement interventions that are tailored to
the needs of their clinic and patients.
Resources
▪ The National Vaccine Advisory Committee’s The
Standards for Pediatric Immunization Practice
(http://archive.hhs.gov/nvpo/nvac/standar.html),
Standard 1.
▪
▪
▪
Immunization Assessment: MIIC User Guidance and
Training Resources
(http://www.health.state.mn.us/divs/idepc/immun
ize/registry/hp/trainassess.html).
The National Vaccine Advisory Committee’s The
Standards for Pediatric Immunization Practice
(http://archive.hhs.gov/nvpo/nvac/standar.html),
Standard 14.
Healthy People 2020 Topics & Objectives:
Immunization and Infectious Diseases
(https://www.healthypeople.gov/2020/topicsobjectives/topic/immunization-and-infectiousdiseases).
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A GUIDE TO AFIX SITE VISIT STRATEGIES FOR QUALITY IMPROVEMENT
Question
Discussion Points
4. Do you
schedule the
next
vaccination
visit before the
patient/parent
leaves the
office?
Scheduling the next vaccination visit before the patient/parent leaves the office
ensures that they have the opportunity to select a convenient time for their visit.
For most clinics, it is easier to track patients who schedule an appointment but
do not show up than it is to identify patients who should have scheduled an
appointment and did not.
This intervention also affords the provider/practice the opportunity to provide
notification about the importance of vaccination and convenient vaccination
services that suit patient availability.
If the clinic does not currently schedule the next appointment before the
patient/parent leaves the office but is open to the idea, IPI advisors should help
the clinic identify changes that can be made. Does the EHR or scheduling system
allow visits to be scheduled months in advance? If not, are changes possible?
Simple interventions, like directing patients to leave through the reception area,
can be an effective way to get patients/parents to schedule the next visit before
leaving the clinic.
5. Do you contact
patient/parent
within 3‐5 days
when a well‐
child or
immunization
only visit is a
no-show and
reschedule the
visit as soon as
possible?
Rescheduling patients within a short time period (3‐5 days) of missing their visits
not only provides a longer time frame for bringing them up‐to‐date on their
vaccinations but it also stresses the importance of immunizations and catching
up on missed opportunities. For more information on recalling patients, see
Question 1.
Resources
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A GUIDE TO AFIX SITE VISIT STRATEGIES FOR QUALITY IMPROVEMENT
Question
Discussion Points
Resources
6. Do you have a
system in
place to
schedule
wellness visits
for patients
who are
between 11‐12
years of age?
A system for scheduling patients ages 11‐12 years for a wellness visit enables
▪
providers to assess and administer vaccination services to an important
adolescent age group for receiving ACIP-recommended Tdap, HPV, and MCV
vaccines. Once again, MIIC can be used to run a list of active adolescents, or to
run a list of adolescents who are due for immunizations. Encourage the clinic to
explore the options that are available to them.
Also, use other adolescent visits, like sick visits or sports physical visits, to screen
for immunizations.
Using Lists in MIIC: MIIC User Guidance and Training
Resources
(http://www.health.state.mn.us/divs/idepc/immuniz
e/registry/hp/trainlists.html).
7. Do you have
an
immunization
champion at
this practice
that focuses
on QI
measures,
reducing
barriers, and
improving
coverage
levels?
Immunization Champions can foster motivation and track progress toward goals. ▪
An immunization champion can have any role within a clinic. For example, they
may be a physician, office manager, clinical services coordinator, or medical
▪
assistant. No matter what role, an immunization champion will be most
successful if there is institutional and external support for quality improvement.
If the clinic has an immunization champion, make sure that person knows who to ▪
contact at the state, MIIC region, and county level for necessary improvement
resources.
▪
MIIC User Guidance and Training Resources
(www.health.state.mn.us/divs/idepc/immunize/regis
try/hp/train.html).
MIIC Regions and Regional Coordinators
(www.health.state.mn.us/divs/idepc/immunize/regis
try/map.html).
Minnesota Vaccines for Children Program (MnVFC)
(www.health.state.mn.us/divs/idepc/immunize/mnv
fc/index.html) site.
As part of the CDC‐supported publication “4 Pillars
Standing Orders Program Toolkit To Increase Child
Influenza Immunizations,” the fourth pillar,
Motivation – Office Immunization Champion Tracks
Progress Towards a Goal, recommends having an
immunization champion at a practice to foster
motivation and track progress. A successful
vaccination program includes an office immunization
champion who tracks progress towards a goal.
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A GUIDE TO AFIX SITE VISIT STRATEGIES FOR QUALITY IMPROVEMENT
Question
Discussion Points
Resources
8. Do you
regularly
document
vaccine
refusals and
reasons for
refusals
(parent
choosing to
delay, parent
has vaccine
safety concern,
medical
contraindicatio
n, etc.)?
Documenting parent refusal of vaccination supports risk liability and provides
▪
data that the vaccine was offered and that the parent of the patient refused.
It is recommended that vaccine refusals be documented with every visit. Patients
▪
and parents should be informed about vaccine benefits and risks even if they
refuse to vaccinate. Federal law requires that this communication include
providing parents/patients with Vaccine Information Statements (VIS).
Recommendations:
▪
If clinic does not currently track vaccine refusals, help them figure out the best
system to do so. Does the clinic use paper charts? If so, a paper refusal form is a
good option. MIIC also can track vaccine refusals, depending on the clinic’s
method of transmitting data to MIIC.
MDH’s Vaccine Safety
(www.health.state.mn.us/divs/idepc/immunize/safet
y/index.html) page.
The National Vaccine Advisory Committee’s The
Standards for Pediatric Immunization Practice
(http://archive.hhs.gov/nvpo/nvac/standar.html),
Standard 9.
American Academy of Pediatrics’ Documenting
Parental Refusal to Have Their Children Vaccinated
(https://www.aap.org/en-us/advocacy-andpolicy/aap-healthinitiatives/immunization/Pages/refusal-tovaccinate.aspx) page.
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A GUIDE TO AFIX SITE VISIT STRATEGIES FOR QUALITY IMPROVEMENT
Strategies to Decrease Missed Opportunities:
Question
1. Does your
immunization staff
educate parents
about
immunizations
and the diseases
they prevent, even
when the parents
refuse to
immunize?
Discussion Points
Studies show that physician and other health care
professionals’ recommendations are central to vaccine
acceptance. Parents need to know about the importance of
vaccination, the availability of vaccines, and the availability of
convenient vaccination services.
Federal law requires that health care staff provide a Vaccine
Information Statement (VIS) to a patient, parent, or legal
representative before each dose of certain vaccinations. This
is an information sheet produced by the CDC that explains
both the benefits and risks of vaccine to vaccine recipients.
2. Do you have
immunization
information and
resources to help
answer questions
from
patients/parents?
Messages notifying parents/patients about the importance of
vaccination and the availability of convenient programs can
be delivered via email, on‐hold messages, office posters,
social media, public service announcements, and videos.
Many organizations have developed immunization
information resources and outreach materials that can be
made available for you to assist with your
information/education efforts.
3. Is your
immunization staff
knowledgeable
and comfortable
with current ACIP
recommendations,
including
Resources are available to help clinic staff that do not feel
they have enough knowledge about the immunization
schedule.
Stress that the practice wants to keep patients as protected
as possible; using the ACIP-recommended schedule is optimal
and endorsed by your practice.
Resources
▪ MDH’s Vaccine Safety Basics
(www.health.state.mn.us/divs/idepc/immunize/safety/basics.ht
ml) page.
▪ MDH’s Reliable Sources of Immunization Information
(www.health.state.mn.us/divs/idepc/immunize/safety/imminfo.
html) page.
▪ Children’s Hospital of Philadelphia’s Parent’s PACK:
(www.chop.edu/service/parents-possessing-accessingcommunicating-knowledge-aboutvaccines/home.html?id=79354).
▪ CDC’s Vaccine Information Statements (VIS)
(www.cdc.gov/vaccines/hcp/vis/index.html) page.
▪ Immunization Action Coalition’s Vaccine Information Statements
(www.immunize.org/vis) page.
▪ CDC’s patient education and conversation training page For
Healthcare Professionals/ Providers
(www.cdc.gov/vaccines/hcp.htm).
▪ American Academy of Pediatrics’ AAP Immunization Grant
Programs
(http://www2.aap.org/immunization/about/programfacts.html)
page.
▪ Immunization Action Coalition’s Parent Handouts
(www.immunize.org/handouts/discussing-vaccines-parents.asp).
▪ The Children’s Hospital of Philadelphia’s Vaccine Education
Center
(www.chop.edu/service/vaccine-education-center/home.html).
▪ CDC’s Immunization Courses: NetConferences, Webcasts, and
Self Study (www.cdc.gov/vaccines/ed/courses.htm).
▪ CDC’s Advisory Committee on Immunization Practices (ACIP)
(www.cdc.gov/vaccines/acip/index.html) page.
▪ MDH’s “Guide to Contraindications and Precautions to
Commonly Used Vaccines” on the Screening and Assessing
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A GUIDE TO AFIX SITE VISIT STRATEGIES FOR QUALITY IMPROVEMENT
Question
minimum
intervals,
contraindications,
etc.?
Discussion Points
MIIC has a vaccine forecaster based on the ACIP schedule
that shows which vaccines are due or past due. Use this as a
tool to determine which vaccines should be administered.
4. Do you train front
desk/scheduling
staff so they know
when it’s
appropriate to
schedule
immunization
appointments?
5. Do you have
standing orders
for registered
nurses, physician
assistants, and
medical assistants
to identify
opportunities to
administer all
recommended
pediatric/adolesce
nt vaccines?
Front desk staff play a key role in making sure that
appointments are scheduled appropriately, to avoid missed
opportunities. Train the staff regularly on the importance of
proper scheduling to lessen patient no‐shows. Also train
them on the current immunization minimum intervals and
minimum ages to reduce invalid doses, and on the use of the
MIIC forecaster along with the clinic’s scheduling software.
Standing orders authorize nurses, pharmacists, and other
health care personnel (where allowable by state law) to
assess a patient’s immunization status and administer
vaccinations according to a protocol approved by an
institution, physician, or other authorized practitioner. The
protocol enables assessment and vaccination without the
need for examination or direct orders from the attending
provider at the time of the interaction.
In settings that require attending provider signatures for all
orders, standing order protocols permit assessment and
vaccination in advance of the provider signature.
6. Is your
immunization staff
knowledgeable
and comfortable
with administering
Patients/parents trust their health care providers as a
valuable source of information about immunizations.
Providers and clinic staff should be knowledgeable and
comfortable answering questions and concerns.
Resources
(http://www.health.state.mn.us/divs/idepc/immunize/hcp/prov
guide/screen.html) page.
▪ “Interpreting a MIIC Vaccination Record” document on the MIIC
User Guidance and Training Resources
(http://www.health.state.mn.us/divs/idepc/immunize/registry/h
p/train.html) page.
▪ The National Vaccine Advisory Committee’s Standards for
Pediatric Immunization Practice
(http://archive.hhs.gov/nvpo/nvac/standar.html), Standard 4.
▪ “Interpreting a MIIC Vaccination Record” document on the MIIC
User Guidance and Training Resources
(http://www.health.state.mn.us/divs/idepc/immunize/registry/h
p/train.html) page.
▪ CDC’s Immunization Courses: NetConferences, Webcasts, and
Self Study (www.cdc.gov/vaccines/ed/courses.htm).
▪
▪
▪
▪
▪
▪
Immunization Action Coalition’s Standing Orders for
Administering Vaccines (www.immunize.org/standing-orders/)
page.
MDH’s sample Vaccine Protocols
(www.health.state.mn.us/divs/idepc/immunize/hcp/protocols/i
ndex.html) page.
The Community Guide’s Increasing Appropriate Vaccination:
Standing Orders
(www.thecommunityguide.org/vaccines/standingorders.html)
page.
The National Vaccine Advisory Committee’s The Standards for
Pediatric Immunization Practice
(http://archive.hhs.gov/nvpo/nvac/standar.html).
CDC’s Immunization Courses: NetConferences, Webcasts, and
Self Study (www.cdc.gov/vaccines/ed/courses.htm).
CDC’s Pink Book
(www.cdc.gov/vaccines/pubs/pinkbook/index.html) page.
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A GUIDE TO AFIX SITE VISIT STRATEGIES FOR QUALITY IMPROVEMENT
Question
all recommended
vaccinations to
patients at every
visit?
Discussion Points
Resources
▪ The National Vaccine Advisory Committee’s The Standards for
Pediatric Immunization Practice
(http://archive.hhs.gov/nvpo/nvac/standar.html),
Standard 8.
Strategies to Improve Completeness and Accuracy of Immunization Information in MIIC:
Question
1. Does your staff
report all
immunizations
you administer at
your clinic (or
practice) to the
Minnesota
Immunization
Information
Connection
(MIIC)?
2. Does your staff
report
immunizations
previously
administered to
your patients by
other providers to
MIIC (official shot
record, other
MIIC report, copy
of medical
record)?
Discussion Points
Introduce MIIC and its capabilities. Explain the importance of
reporting all administered immunizations to MIIC to generate
complete and up‐to‐date coverage assessment reports. If
administered vaccines are not reported to MIIC in a timely and
complete manner, the coverage rates generated are not
accurate and cause missed opportunities for the assessing
provider.
Also be sure to refer clinic staff to their region’s MIIC Regional
Coordinator for additional training and guidance.
Resources
▪ Minnesota Immunization Information Connection (MIIC)
(www.health.state.mn.us/divs/idepc/immunize/registry/index.ht
ml) website.
▪ MIIC User Guidance and Training Resources
(www.health.state.mn.us/divs/idepc/immunize/registry/hp/train.
html).
▪ MIIC Regions and Regional Coordinators
(www.health.state.mn.us/divs/idepc/immunize/registry/map.ht
ml).
Providers should report to MIIC all immunizations known to
have been administered to a patient, regardless of whether
the immunizations were administered by the provider’s office
or by another provider. This helps ensure that every patient
has a complete, consolidated vaccination history in MIIC and
that the provider’s coverage assessments reflect the true
vaccination coverage for the patient population served.
▪
▪
“Reporting Immunization Data to MIIC” document on the
Submitting and Exchanging Data with MIIC
(www.health.state.mn.us/divs/idepc/immunize/registry/hp/data.
html) page.
“Entering New Clients” and “Adding Shots” documents on the
MIIC User Guidance and Training Resources
(www.health.state.mn.us/divs/idepc/immunize/registry/hp/train.
html) page.
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A GUIDE TO AFIX SITE VISIT STRATEGIES FOR QUALITY IMPROVEMENT
Question
3. Do you inactivate
patients in MIIC
who are no longer
seen by your
practice?
4. Do you use MIIC
to determine
which
immunizations
are due for each
patient at every
visit?
Discussion Points
Maintaining accurate patient lists makes MIIC functions, like
reminder/recall, more accurate for the clinic. MIIC’s Client
Follow-Up function can help clinic staff inactivate patients that
no longer are a part of their practice. This way, any
reminder/recall activities will only send messages out to
patients who are still part of the clinic’s population.
The immunization schedule is complex, and it is difficult to
forecast, especially for a patient not on a regular
immunization schedule.
MIIC has a forecaster that uses algorithms to determine which
vaccines are due on the date of service. Forecasters should be
used along with the patient’s medical record and the
clinician’s judgment to determine what is due.
Resources
▪ “Using Client Follow-Up for Mass Inactivation” document on the
Client Follow-Up: MIIC User Guidance and Training Resources
(http://www.health.state.mn.us/divs/idepc/immunize/registry/h
p/traincfu.html) page.
▪
▪
“Interpreting a MIIC Vaccination Record” document on the MIIC
User Guidance and Training Resources
(http://www.health.state.mn.us/divs/idepc/immunize/registry/h
p/train.html) page.
The National Vaccine Advisory Committee’s The Standards for
Pediatric Immunization Practice
(http://archive.hhs.gov/nvpo/nvac/standar.html), Standard 4 and
Standard 9.
Minnesota Department of Health
Minnesota Immunization Information Connection
PO Box 64975, St. Paul, MN 55164-0975
651-201-5207
[email protected]
To obtain this information in a different format, call: 651-201-5503.
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