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WIC Immunization Referral Process
Summary
Impact Statement:
The local health department increased the number of infants and children receiving needed vaccines as part of a WIC visit, rather than referring them to another site and potentially losing that opportunity to protect them from getting a preventable disease or transmitting a vaccine-preventable disease to others in the community.
Summary:
The purpose of this quality improvement (QI) project was to increase the number of children who present with vaccination needs that receive these vaccines on the same day as WIC services. Initial data collection indicated that infants and children receiving WIC services had incomplete vaccination rates as high as 68%. By improving the knowledge and motivation of WIC staff regarding immunization requirements and providing a full Michigan Care Improvement Registry (MCIR; immunization database) printout, immunization rates rose significantly. Over a 6-month period, St. Clair County increased by more than 50% the number of WIC infants and children who received immunizations during the same WIC visit.
Organization that conducted the QI initiative:
St. Clair County Health Department
Citation:
Sturgis, M. Public Health Quality Improvement Exchange. WIC Immunization Referral Process. Thu, 12/27/2012 - 12:46. Available at http://www.phqix.org/content/wic-immunization-referral-process. Accessed April 25, 2024.
Background and Aim
Aim statement:
By January 2011, St. Clair County Health Department will increase by 50% the number of WIC infants and children who receive immunizations during the same WIC visit.
Need For The QI Initiative:
Low immunization rates among WIC infants and children had been an ongoing issue at St. Clair County Health Department. When the opportunity arose to engage in a quality improvement project with support from the Michigan Public Health Institute (MPHI), Dr. Mercatante (Health Officer) and Elaine Kempf (Administrator) immediately knew this would be the focus of their proposal.
Administrators from the department reviewed immunization data and discovered that, among the 2,999 children enrolled in the WIC program, only 50% were up to date on their immunizations. As a result, it was determined that our QI project would be to increase the number of WIC infants and children to receive their vaccines the same day as their WIC service. In a review of vaccine referral rates it was determined that very small numbers of WIC clients who need immunizations actually received vaccines on the same day of service. Baseline data collected in April 2010 revealed the same information and led us to conclude that we needed to identify barriers to children receiving immunizations during their WIC visit.
Area for Improvement:
One-day MCIR assessment of 75 WIC infants and children revealed the following immunization statuses:
17% were overdue for immunizations.
12% were up to date.
53% were eligible for immunizations.
However, none received immunizations during their visit.
Root Cause:
WIC clients are referred to the department’s Preventive Health & Immunization Division to receive recommended shots on the day of their visit. The WIC clerk-tech is required to go into the Michigan WIC data screen and determine immunization status. If a client is determined to be “not up to date” or “eligible,” then they are provided with limited immunization information, referred to the Immunization Division and the rest of the WIC visit continues. However, WIC and Immunization staff are aware of many barriers to parents actually following through with the referral. In addition to adding time to the WIC visit and the temperament of the child, the Immunization Division is in another part of the health department building and two flights of stairs in between create barriers for mothers with small children and infants in strollers.
Planning and Execution Details
QI Implementation:
To identify barriers to WIC clients having their children immunized during their WIC visit, the team engaged in preparing a fishbone diagram. Team members brainstormed all possible factors that could have an impact on parents/caregivers following through with referrals. It became evident that lack of knowledge, on the part of health department staff, clients and possibly physicians emerged as a consistent barrier in the process. Data were collected for 2 weeks to gather pre-intervention referral rates.
During this period, new pneumococcal recommendations were released and the WIC clerk-tech was educated about this during MLC-3 team meetings. As a result, when a WIC client was determined to be not up to date by the MIWIC program, the WIC clerk-tech discussed with the parent that this was the probable cause of the client’s status.
Data were startling! 71% of those referred for immunizations who were told it was because of the new pneumococcal requirements were successfully referred. This was contrary to what preliminary assessments had suggested.
It was perceived that, because of the increased level of knowledge and confidence on the part of the WIC clerk-tech, parents were more likely to follow through with the referral and take their children to the Immunization Division for shots.
QI Tools:
Initiative Dates:
3/31/10 to 9/30/10
Initiative Duration:
Between 6-12 months
Methods of evaluation:
The WIC clerk-tech developed a “check sheet” to track client responses to immunization referral. Data was collected from 7/22/10 through 8/17/10 by the WIC clerk-tech and immunization staff.
The WIC check sheet was then compared to a summary sheet printed by the immunization clerk to determine successful referral rate.
Clients gave different reasons for refusing referral and several reasons were given consistently. An MCIR sheet will be printed for every WIC infant and child deemed not up to date or eligible for vaccines and presented to parent/caregiver at every WIC visit. WIC clerk-techs, utilizing educational tools developed to increase level of knowledge, will continue to refer infants and children to immunization division with increased confidence.
WIC clerk-tech will tally responses to referrals daily and maintain in check sheets in notebook.
1. A series of educational video segments was uploaded to the county intranet for all HD staff to access and view. The goal was to establish a baseline level of vaccine knowledge among all staff, regardless of their job description. All employees who took the quiz after viewing the video segment were eligible for a drawing to win the prized parking spot close to the building entrance in the employee parking lot.
2. A “vaccine quick reference sheet” was developed that briefly described each vaccine and the diseases they prevent in easy to understand language. The reference guides were laminated and given to each clerical unit for easy access.
Other Information:
The significant problems with staff participation in QI activities remain unchanged as state and county budgets continue to dwindle. Much attention is focused on volume-based reimbursement, even at the local health department level. A balance between programmatic requirements and the value of refining, expanding, and assessing duties will remain challenging. It is important to foster a culture of willingness and desire for this activity to make it happen. This comes from leadership that values and promotes these qualities in themselves and in their staff. Maintaining QI activities requires at least one dedicated staff member who has been trained and assigned this task in his/her job description. Current economic conditions make this difficult but not impossible to accomplish.
Supplemental Materials:
Initiative photo(s)
Report
Storyboard
Results
Measurable QI Outcomes:
Participation in video clip viewing declined over time.
Computer hardware programs were a barrier to all staff having the opportunity to view video clips.
Distribution of vaccine quick reference sheet was not widespread 176 clients were seen by WIC staff during the 1 month of data collection.
111 (63%) were deemed eligible for vaccination.
70 (63%) of the 111 clients indicated willingness to receive vaccines.
77% of those were successfully vaccinated.
A attempt to survey those who failed to receive vaccines failed, because clients were difficult to reach via phone calls.
Other QI Outcomes:
As a result of the initiative, we have continued to review MCIR data on every child arriving for a WIC visit who in not up to date in the Michigan WIC system. WIC clerks took responsibility for printing the MCIR sheets for each client who were determined to be not up to date or eligible for immunizations.
The need for organizational restructuring was partially based on the clear barriers illustrated through this process. Improved familiarity between programs has fostered cross-training between departments, which is inherently important in a diminishing work force.
Lessons Learned, Observations and Insights:
The tools and strategies learned from the MLC-3 process have greatly contributed to improved teamwork and collaboration of St. Clair County Health Department. Many barriers were broken down in a very short time, and the need for further workgroups was enthusiastically embraced. Administration has a well-defined process to apply to areas needing improvement and a core team has been trained to develop and maintain this process. Like a central core of a wheel, the spokes that represent each participant will radiate out to other areas they interact in. In this way, the whole “wheel” becomes stronger and faster.
A difficulty identified in this initiative was the significant problem with staff participating in meetings, teleconferences and webinars due to the inflexibility of schedules. This likely will remain a significant barrier. Particular resistance was noted in the WIC supervisory staff due to the success of the WIC program—change was rebuked as the program was performing well prior to the initiative.
Future Plans:
WIC clerks will pull MCIR assessments for all WIC infants and children determined to be either eligible or not up to date who are presenting for service.
A WIC staff person will review MCIR findings with the client and refer to immunizations for service that day.
Close communication will be maintained between divisions to facilitate expedient client service, particularly during lunch and at the end of the day.
Infant/child immunization rates will consistently be reviewed during WIC and Nursing Division staff meetings.
Video clips as an educational tool will be utilized again with format changes and equipment updates.
Identify alternative WIC staff person (dietitian) to review MCIR data in absence of WIC clerk-tech.
The team celebrated its success!
Project team members were “gifted” with scientific method t-shirts from Dr. Mercatante.
Project team members all believed the project was a great opportunity to “walk a mile” in a co-worker’s shoes and gain respect and appreciation for each others’ roles in public health service delivery.
Plans to share with Board of Health, Board of Commissioners and other HD staff:
Project information was shared at annual staff training in September 2010.
Special recognition was given to project team at staff development event in December 2010.
Administration plans to share information on the project with the Board of Health and the Board of Commissioners.
Selected team participants will lead future QI projects.
Plans for future projects:
Administration has selected another project for QI, and team member selection is under way.
Plans to sustain QI efforts:
A designated QI coordinator will be identified with duties assigned.
QI will be integrated into health department operations and will become a routine activity for staff.
It is administration’s goal to eventually involve all health department staff in the process by rotating the projects throughout all divisions. A multi-divisional approach will be utilized to create unity and heighten awareness among all staff of each other’s role in providing service.
Training and Preparation
Technical Assistance Received:
Technical assistance regarding storyboard provided to Susan Amato by MLC-3 staff.
QI Related Training Received:
The following staff members attended a 2-day learning session in Okemos, Michigan, offered by the Multistate Learning Collaborative 3 (MLC-3) year: Christina Dean, Margaret Sturgis, Susan Amato, Melanie Dunsmore, and Janet Herriman.
Information about the Community
Population Size:
Population Characteristics:
The St. Clair County Health Department serves the thumb area of the eastern lower peninsula of Michigan, bordering Canada. It is at the mouth of Lake Huron and along the St. Clair River, which is part of the St. Lawrence Seaway. St. Clair County covers an area of 724 square miles, and the city of Port Huron serves as the county seat. 56% of the county’s population lives in urban areas, with the rural population distributed as 1.5% on farms and 43% rural nonfarms. The service delivery area is 94% white, 2% African American, 2% Hispanic, and 1.3% other. The jobless rate for the city of Port Huron as of April, 2010 was 23% and 16.8% countywide (well above the state and national average). 10.5% of St. Clair County residents live in poverty, over 50% are female-headed single parent families, and of those, more than 67% have children younger than 6. 52% of the Port Huron–area school children receive free or reduced lunches. The number of children with Medicaid has increased 29%, and the number of children receiving food stamps has increased 211%. The WIC program has seen a 15% increase in infants and children receiving WIC benefits. Immunization rates for children aged 13 to 71 months (6 years) in May 2012 were lower than 2007, with incomplete vaccination rates as high as 68% for the most vulnerable age group. St. Clair County has the first reported pertussis death in Michigan in February 2010, with the tragic loss of a 3-month-old infant.
Information about the Health Department
Local Health Department Governance:
Local Governance - all LHDs in the state are units of local government
PHAB Accreditation Status:
Planning to submit application for accreditation in the next year
State-based accreditation?:
Yes
Accreditation Date:
11/1/09
Annual QI Initiative Frequency:
QI activity level:
Organization Type:
QI Staff Information
Total number of Staff on QI Team:
11
QI team members:
Role in the Initiative:
Project Lead
Role in Organization:
St. Clair County Health Education Director/Media Spokeswoman
FTE:
0.20
Name (Optional):
Susan Amato
Role in the Initiative:
Team Member
Role in Organization:
St. Clair County Medical Health Officer
FTE:
0.20
Name (Optional):
Annette Mercatante, MD, MPH
Role in the Initiative:
Team Member
Role in Organization:
Administrator
FTE:
0.10
Name (Optional):
Elaine Kempf
Role in the Initiative:
Team Member
Role in Organization:
Maternal Infant Health Nursing Supervisor
FTE:
0.10
Name (Optional):
Melanie Dunsmore, RN
Role in the Initiative:
Team Member
Role in Organization:
MDCH Immunization Field Representative
FTE:
0.10
Name (Optional):
Kevin Czubachowski, RN
Role in the Initiative:
Team Member
Role in Organization:
WIC Health Care Technician
FTE:
0.20
Name (Optional):
Christina Dean
Role in the Initiative:
Team Member
Role in Organization:
Clerk
FTE:
0.20
Name (Optional):
Janet Herriman
Accreditation Details
PHAB Standards:
Domain 7: Promote strategies to improve access to health care services›Standard 7.1 Assess Health Care Service Capacity and Access to Health Care Services
Domain 7: Promote strategies to improve access to health care services›Standard 7.2 Identify and Implement Strategies to Improve Access to Health Care Services
Collaborations
Partner Organizations:
Mid-Michigan Health Department
Partner Organization Types:
Contact Information of the Submitter
First Name:
Margaret
Last Name:
Sturgis
Organization:
St. Clair County Health Department
Submission Status:
Completed
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