School Immunization Record Review Project

Summary

Impact Statement:

Compliance with required school immunizations rose after completion of a review of school immunization records was coupled with better methods of contacting parents. As a result, both children and the wider community experienced less spread of diseases.

Summary:

Children attending public schools in Washington State are being exempted from important immunizations that prevent the spread of disease. Children without all the necessary immunizations required to attend school must present a signed Certificate of Exemption (COE) to attend school. The exemption rate for grades K–12 in Spokane County for the 2008–09 school year was 7.4%, compared to 5.7% for the state. This equates to approximately 5,300 students in Spokane County with an exemption to some or all immunizations required for school entry. Out of all 36 counties in Washington, Spokane had the 10th-highest exemption rate for the 2008–09 school year. By increasing vaccination rates and decreasing exemption rates, there will be less spread of diseases among Spokane’s children and the wider community.

This quality improvement project was conducted in the first half of 2010. Since then, additional funding has been awarded to continue this work through 2014.

Organization that conducted the QI initiative:

Spokane Regional Health District

Citation:

Siahaya, K. Public Health Quality Improvement Exchange. School Immunization Record Review Project. Fri, 03/29/2013 - 19:30. Available at https://www.phqix.org/content/school-immunization-record-review-project. Accessed October 10, 2024.

Background and Aim

Aim statement:

The overarching goal of this project is to reduce vaccine-preventable diseases by increasing the number of students who have received required school-entry vaccines. The two specific objectives were the following: (1) by July 31, 2010, personal exemption rates will decrease by 15.0% for all participating school districts; and (2) by July 31, 2010, immunization rates will increase by 15.0% for all participating school districts.

Need For The QI Initiative:

Immunization exemption rates have been steadily increasing in Spokane County. During the 1997–98 school year the exemption rate was only 2.8% and during the 2001–02 school year it rose to 5.5%. According to the 2009–10 data, the rate is up to 8.0%. With steadily increasing exemption rates and steadily increasing demands on school nurses and office staff, following up on missing immunizations and warning parents of the risk of exempting their children from immunizations is becoming more difficult for schools. This initiative was chosen after research of immunization rates and exemption rates was conducted as well as attending meeting with school partners. School partners wanted help to ensure they had accurate data and were ultimately protecting children in their schools from the spread of preventable disease. This improvement project addresses this public health issue by increasing reliable data to ensure school-age children are protected from vaccine-preventable disease. The practice helps to ensure that the exemptions on file are true exemptions. Due to the rush to get children registered for school, some parents sign exemption forms even when their children may have the vaccines or will be getting the vaccines. Parents also rarely remember to request the exemption be removed from the child’s record, even when they have received the appropriate vaccines. Since this project was completed, Washington State law has changed to now require a medical signature for all personal and medical exemptions. This new law will most likely decrease the convenience exemptions that occurred during school registration.

Area for Improvement:

Children attending public school in grades K–12 in Washington State who do not have all the necessary immunizations for school entry must present a signed Certificate of Exemption (COE) to attend school. The exemption rate for grades K–12 in Spokane County for the 2008–09 school year was 7.4%, compared to 5.7% for the state. This equates to approximately 5,300 students in Spokane County with an exemption to some or all immunizations required for school entry. Out of all 36 counties in Washington, Spokane had the 10th-highest exemption rate for the 2008–09 school year. Spokane’s immunization exemption rates have also been steadily increasing. By increasing vaccination rates and decreasing exemption rates, there will be less spread of diseases among Spokane’s children and the wider community. In order to begin addressing these rates, Spokane Regional Health District’s (SRHD’s) Immunization Outreach and Public Health Emergency Preparedness and Response (PHEPR) programs partnered on a project to review the immunization records of school-aged children. The purpose of this project was to reduce the number of immunization exemptions on file and increase the number of children who have received the state-required vaccines for public school attendance within Spokane County. The overall goal of this project was to decrease vaccine-preventable disease by increasing the number of children and adolescents who receive recommended vaccines. SRHD hired six temporary staff and increased the hours of one internal employee to work on this project. SRHD collaborated with five school districts in Spokane County (Spokane Public Schools, Mead School District, Deer Park School District, East Valley School District, and West Valley School District). SRHD and the participating school districts worked together to review immunization records by contacting parents via letter or phone. According to school data for 2008–09, the five school districts represent approximately 49,000 students, or about 68.0% of the children attending public school in Spokane County. SRHD serves Spokane County, which had a population of about 470,300 people in 2010. A total of 8,570 immunization records were reviewed for the project. Records of children who had received all appropriate, required immunizations for school entry were not reviewed. The 8,570 records represent about 17.5% of the total students in the targeted five school districts.

Root Cause:

• School staff do not have time to review records • Ease of availability of exemption form during registration process • Having an exemption on file makes the students “legal” to attend school, so why take staff time to follow up with parents • Do not have a standardized tracking system or tracking tools • School funding is determined by the number of students in the seats • Parents are hard to reach to get updated information • Immunization records are not a priority for school nurses in the beginning of school when they are working on Educational Plans for kids with life-threatening illnesses • Schools do not know the importance of maintaining accurate records • Schools do not think it should be their job to monitor immunizations • There are many records that are not accurate because staff have never followed up with parents regarding inadequate records

Planning and Execution Details

QI Implementation:

Through a series of internal meetings and meetings with school partners, brainstorming around the issue of immunization school records was conducted. Discussions were aimed at developing a project that would address both high exemption rates in Spokane County and accuracy of school immunization records. Through these brainstorming discussions, root causes were discussed. The groups determined which root causes were within the scope of a 6–8 month quality improvement (QI) project. The timeline was determined by the funding source.

Focus activities

Immunization:

Childhood Immunizations- administration of vaccine to population

QI Methods:

PDCA/PDSA Cycle (Plan, Do, Check/Study, Act)

QI Tools:

Brainstorming

Root cause analysis

Initiative Dates:

1/1/10 to 8/31/10

Initiative Duration:

Between 6-12 months

Methods of evaluation:

A standardized tracking sheet was used to track the outcomes measures for compliance and exemption rates. The tracking sheet logged contact attempts to the parent as well as exemption and compliance, by student ID number. The baseline data were either generated by the school computer system, or were calculated by hand. Every school has a different way of tracking immunizations. The baseline data were put into the standardized tracking spreadsheet in Excel, and this was used throughout the project. At the end of the project, the data were imported into a statistical analysis program called STATA. Overall, the total percentage of students in compliance increased from 1.7% to 23.0% of students not in compliance. This was a 21.3 percentage point increase. A process measure was analyzed looking at the effectiveness of contact methods made to parents to update the immunization records. Some school districts used only letters, some used a letter plus a phone call, and others used only phone calls to contact parents. Overall, there was significantly more improvement in vaccination rates when using only phone calls to contact parents, compared to only sending letters or to sending letters and then calling parents. For most immunizations and as an overall strategy, only making phone calls to parents worked the best. Overall, the total percentage of students in compliance increased from 0% to 31.6% of students not in compliance who were contacted by this method. This was a 31.6 (+/-4.6) percentage point increase.

Supplemental Materials:

Report

Certificate from NACCHO for Promising Practice

Supplemental Files:

Attachment	Size
NACCHO Certificate.jpg	1.3 MB
SRHD School Record Review Project.pdf	474.21 KB

Results

Measurable QI Outcomes:

There were a total of 8,570 out-of-compliance records reviewed by staff to ensure students had received appropriate vaccines for school entry. There were several reasons a student would not have appropriate vaccines according to each school’s immunization tracking system. The most common reasons were that students’ records did not have a date of vaccination for a particular vaccine, there was an exemption on file for that vaccine, or vaccination dates were not valid due to intervals or age requirements. Overall, the number of students who were compliant after review rose to 23.0% by the end of the project across all five school districts. The objective to decrease personal exemption rates by 15.0% was not met. Since exemptions are tracked by vaccine, the personal exemption rates were evaluated by vaccine type and are shown below in the graph. Decreases in personal exemptions ranged from 2.3% to 3.7%.

Other QI Outcomes:

This project was successful in increasing vaccination rates and decreasing out-of-compliance and personal exemptions. In order to continue this work in the future, schools in Spokane County would need to take on the work of this project. With all the lessons learned and information SRHD has gathered, it was determined that a toolkit could be provided to the school districts that would give them examples of resources and step-by-step instructions on how to continue to review their records every year to ensure the data is accurate. SRHD received two additional grants from the Group Health Foundation to continue this work. The first grant is to develop a toolkit for schools and childcares for a historical record review. After this grant was received and SRHD did the initial root cause analysis, it became apparent that a best practice for schools on how to perform immunization record keeping and tracking was also needed in order to keep records current and accurate from year to year; just performing the historical record review was not enough. The second grant was awarded to develop a statewide best practice immunization record-keeping tool. With support from the Department of Health, Tacoma Pierce County Health Department, and other school partners, SRHD was able to get this additional funding. Since the second funding was awarded, SRHD has also gained support from the Office of Superintendent of Public Instruction. These additional funds and projects will go through the first quarter of 2014.

Lessons Learned, Observations and Insights:

Lessons learned: • Some of the records that were thought to be out of compliance actually were not. Out of the 8,570 records reviewed, 146 (1.7%) did not need any follow-up because they were compliant. • According to the Federal Education Rights and Privacy Act (FERPA), student immunization records are protected and cannot be released to anyone without a parent’s signature except during a declared public health emergency. • All school districts have a different way of recording and tracking school-entry vaccines. • Tracking and gathering immunizations is a burden for schools. In fact, some schools do not believe it is their job to maintain these records.

Future Plans:

With the additional funding and the increased support of these initiatives statewide, the original improvements in Spokane County would be expected to continue statewide. The foundations of this original project will be replicated in 10 other school districts throughout the state during the implementation of the additional funding.

School Immunization Record Review Project

Summary

Background and Aim

Planning and Execution Details

Results

Training and Preparation

Information about the Community

Information about the Health Department

QI Staff Information

Accreditation Details

Collaborations

Contact Information of the Submitter

Comments

Kristi-this is an excellent

QI Spotlight

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School Immunization Record Review Project

Summary

Background and Aim

Planning and Execution Details

Results

Training and Preparation

Information about the Community

Information about the Health Department

QI Staff Information

Accreditation Details

Collaborations

Contact Information of the Submitter

Comments

QI Spotlight