Nj Immunization Record Template

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					 Delivering on the Promise of
   Immunization Registries
Through Collaborative Learning
              and
     Quality Improvement
   39th National Immunization Conference
              Washington, D. C.
               March 22, 2005

           Ruth Gubernick, MPH
              Zina Kleyman
      Presentation Objectives

   Understand the NJ Improving Preventive Services
    Project (NJIPSP) collaborative model

   Understand how an Immunization Registry can
    support quality improvement

   Understand key office-based changes that can be
    made by providers using an Immunization Registry
    to improve immunization services
    Presentation Overview

   The Team, Mission, and Goals
   Expectations, Methods and Change
    Concepts
   Tools and Measures
   Improvements and Lessons Learned
        Immunization Coverage
for 24 Month old Children in New Jersey*


                % UTD (4:3:1:3:3:1)**
       All US                                    66.2
       All NJ                                    67.9
       Newark                                    52.2


         *Estimated, US National Immunization Survey, 2002-2003
         **D,T,P:Polio:MMR:Hib:HepB:Var
We can do better…
                      The Team
   Modified Breakthrough Learning Collaborative which
    includes:
     – 9 Immunization delivery sites (6 active)

     – The American Academy of Pediatrics, NJ Chapter
       Pediatric Council on Research and Education
       (AAPNJ/PCORE)
     – NJ Dept of Health and Senior Services (NJDHSS)

     – Regional Maternal and Child Health Consortia

     – National Initiative for Children’s Healthcare Quality
       (NICHQ)
     – A Model for Improvement

     – Goals and Change Concepts to guide improvement
       efforts
     – Use of the NJ Immunization Information System
       (NJIIS)
              Our Mission
 Improve   delivery of immunization and
  preventive services though improved care
  delivery processes and information technology
 Measurable and sustainable improvements
 Use a Care Model for Child Health that
  emphasizes
    – Prepared, pro-active primary care teams

    – Informed parents and children
    – Effective practice, community, Dept. of PH
      collaboration
 Spread the Model widely
         Goals

Excellent and Equitable
 Immunization Delivery
Enhanced Use of Office Systems
Effective Use of Technology
Improve Other Preventive
 Services
      Expectations: Practices
   Establish a multi-disciplinary team
   Identify and engage a senior administrative leader
    to serve as a sponsor
   Complete pre-work activities to prepare for the
    Collaborative and first Learning Session
   Commit to testing changes and make substantive
    improvements
   Participate in monthly conference calls
   Participate in and follow e-mail communications
    through a “listserv”
   Measure performance though out the project
   Share lessons learned
   Establish Internet access within the practice
   State Project Team (AAP,DPH)
 Provide  information
 Customize the standard Learning Collaborative
 Train practice organizations to use the registry
 Provide methods for implementation of each
  registry as a clinical tool, including assistance
  with community outreach.
 Support collaboration between practices, AAP
  Chapter, NJDHSS, and regional MCHC
 Support an initial transfer of practice-based data
  including immunizations and demographics into
  the registry.
 Work with NICHQ to design a spread plan for
  the statewide deployment of improvements
      Expectations: NICHQ

 Provide   training for the Project and Practice
  teams
 Assist the State Project teams to plan, and
  deliver the Learning Collaborative
 Work with the State and Practice teams to
  design a spread model for the state wide
  deployment of improvements
 Provide National Chairs, Faculty and Project
  Staff for the project and Learning Sessions
              Methods
 Practices and local health departments set
  goals, receive feedback, and embrace the
  registry as a clinical tool, vaccine inventory
  system, and practice
  management/immunization assurance tool
 NICHQ provides models, training, tools, and
  support
 The AAP and DPH provide best practice
  guidance and registry support and
  collaborative leadership
 Everyone works together to design a spread
  plan for statewide deployment of
  improvements
The Changes
                               Six Key Steps in Preventive Service Delivery
                    IDENTIFY
                     PATIENT              PROMPT            DO PREVENTIVE        DOCUMENT         REINFORCE/          TRACK/
                      NEEDS              CLINICIAN             SERVICE            SERVICE          EDUCATE          FOLLOW-UP
                   At every visit

               Have data              Provide clinician    Standardize         Record all     Provide           Perform
                readily available       reminders at          immunization         immunizatio     families with      regular
               Review pt               the time of visit     storage,             ns in a         immunization       recall
                immunization                                  inventory and        computer-       record            Monitor
                record at every                               patient delivery     based          Provide verbal     immunizatio
                visit                                                              system          and printed        n coverage
Objectives
               Integrate with                                                    Enter data      education          rates
                other preventive                                                   at the time     materials
                services                                                           of visit




             [1]   Leininger et al. An office system for organizing preventive services. Arch Fam Med. 1996; 5: 108-15
           The Tools
 NJIIS  with shared website and reporting
 Change Package
 email ListServ communication
 Monthly conference calls with practice
  teams for coaching and sharing of
  innovation
 Learning Sessions (3 full-day sessions)
 Practice Site Visits
NJIIS with shared website and
           reporting
Only Participating Practices can
   login to Special Projects
Special Projects Welcome Page
Practice Monthly Report
   Parameters Page
Individual Practice Monthly
    Assessment Report
Shared Folders can be accessed
  by all participating practices
Practice (cumulative) Run-charts
Participating Practices share their
  Monthly Senior Management
              Reports
Report Template
Other documents and
   presentations
The Measures
Goal: Excellent and Equitable
   Immunization Delivery


   90% of children will have their
    immunizations up-to-date at 24
    months
                                40
                                50
                                60
                                70
                                80
                                90
                               100
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Goal: Excellent and Equitable
   Immunization Delivery


   50% or more decrease in
    immunization disparity between
    children receiving VFC and non-
    VFC vaccines
                    Average/Best
             VFC - % UTD 19-23 Months
100
 90
 80
 70
 60
 50
 40
 30
                  st




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                          Average       Best       non-VFC



* Disparity = -1,8,and 5 for 3 practices with sizeable non-VFC populations
Goal: Enhanced Use of Office Systems


      Immunization System Index (ISI)
       score of 9 or greater
The Immunization Systems Index (ISI)

 1. Common administration policy
 2. Current guidelines available
 3. Preventive services team
 4. Reminder system
 5. Recall system
 6. Immunizations recorded during visits
 7. Needs assessed for all visits
 8. Temperatures recorded twice a day
 9. VIS sheets routinely given
 10. Families given a “patient-held” record
                               5
                                   6
                                       7
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 Goal: Effective Use of Technology


• 95% of immunizations are entered in
  registry within 7 days of administration
                          Average/Best
% of Doses Entered into Registry Within 7 Days

100
 90
 80
 70
 60
 50




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                                 Average      Best
Goal: Effective Use of Technology



• 90% of children < 2 yrs have VFC
  status documented in registry
                 Average/Best
      VFC Status Documented In Registry

100

90

80

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                                 Average    Best
                   One practice’s data….
              (before and during participation)

100.0
 90.0
 80.0
 70.0
 60.0
                                                                  Jan-Jun
 50.0
                                                                  Jul - Dec
 40.0
 30.0
 20.0
 10.0
  0.0
        UTD      UTD    Disp   VFC   Non-   UTD      2      7
         24     19-23                VFC    7-11   shots   days
 What surprises did you have related to this
immunization system improvement project?

      When going into the registry we found that a lot of our
       children are not active with our clinic. We now need to
       send letters and close out cases so we can make them
       inactive in the registry.

      That most of our younger patients were already in the
       registry.

      We seem to be ordering syringes with increasing
       frequencies. Our hazardous waste has also increased
       significantly.

      With lead testing, we learned that we do not follow up on
       patients who were given prescriptions for lead testing. If
       they did not go, there was no result.
             Lessons Learned
   Creating change is hard work and takes time!
   A high level “Champion” is essential
   Monthly reporting must be easy to do
   Using the NJIIS for reporting encourages use
   Ongoing communication is key
     – Registry demos at each LS added value

     – Site visits by Faculty or QI Coordinator
       between Learning Sessions make a difference,
       to reinforce improvement process and registry
       use
   T-E-A-M, YEA TEAM!
         Conclusions/Implications

   Improvement of immunization delivery is possible
    with innovative technology and a commitment
    and plan for continuous quality improvement
    –   Registry supports easy improvement measurement
    –   Teams have learned to try small tests of change and
        take incremental steps forward
    –   Long-term improvement needs to be assessed
   The NJIPSP is a model with the potential to be
    spread to other practices seeking to improve
    immunization delivery with an immunization
    registry
            Acknowledgements
   The NJIPSP is supported by resources from the Centers for
    Disease Control and the NJ Department of Health and
    Senior Services
   NJIPSP coordinators are: Lori Donovan and Anne Lorenzo
    (AAP/PCORE) and Robyn Elder (NICHQ)
   QA Coordinator: Adrienne Millican
   The materials (goals, measures, change concepts) for the
    NJIPSP were developed in collaboration with Kristin Saarlas
    (Public Health Informatics Institute), Peter Margolis (NC
    Center for Children's Healthcare Improvement), Alan Kohrt,
    Lois Kohrt (Children's Hospital of Philadelphia), Katherine
    Wytovich (NJDHSS), Bob Morgan (NJDHSS), Steve Kairys,
    Peter Wenger, Ruth Gubernick, Jane Taylor, Bill Adams,
    Patricia Heinrich (NICHQ) and Charles Homer (NICHQ).
   NJIIS reports were developed by Zina Kleyman, NJDHSS.
        For more information:

Ruth S. Gubernick, MPH
Project Director, NJIPSP
phone: (856) 751-0115
e-mail: gubernrs@hln.com

Zina Kleyman
Project Manager, NJIIS
Phone: (609) 588-3439
e-mail: Zina.Kleyman@doh.state.nj.us

				
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