Assessment,
Feedback, Incentives and eXchange of Information (AFIX)
Standards
This
document starts with a letter describing the intended
use of the standards guide.
Department of Health and Human Services
Public Health Service
Centers for Disease Control and Prevention (C.D.C.)
Atlanta, GA 30333
January 18, 2005
Dear Immunization Program Managers and AFIX Coordinators:
The Assessment, Feedback, Incentive, and eXchange (AFIX)
Standards are an outgrowth of the Immunization Program
Operations Manual (I.P.O.M.). The I.P.O.M. presents information
to programs on “what an effective immunization program
looks like.” The AFIX Standards have a similar purpose
but focus specifically on the AFIX process. The AFIX
Standards are organized in levels, and within each level
there are 6 program components (program operations, assessment,
feedback, incentives and exchange of information and
program evaluation). Each level builds upon the successful
completion of the previous level’s requirements.
Level 1 of the AFIX Standards provides structure on how to
develop, implement and evaluate an effective AFIX program
that will meet all grant requirements. The Standards
describe essential elements for all AFIX programs; they
are also flexible to allow for grantees to address situations
unique to their locale.
The
AFIX Standards are designed to encourage but not require
grantees to continue to improve beyond a fundamentally
sound and effective AFIX program. Levels 2 and 3 provide
guidance for exceeding the requirements for an effective
AFIX program and focus on developing new and creative collaborative
relationships with other organizations
and immunization providers.
The official release of the complete AFIX Standards document
will occur during the National Immunization Conference
in Washington, D.C., March 21–24, 2005. Shortly after
the conclusion of N.I.C., each Immunization Program Manager
and AFIX Coordinator will receive a binder of the
complete set of AFIX Standards, levels 1 through 3. The
binder format has been selected so each grantee can easily
make copies of the document. The complete set of AFIX
Standards will also be available shortly after the NIC
on the National Immunization Program (N.I.P.) Website
at www.cdc.gov/nip/afix.
Should you have any questions regarding the AFIX Standards,
please feel free to contact Nancy Fenlon at (404) 639-8810
or via e-mail at ncf1@cdc.gov.
Sincerely,
Lance E. Rodewald, M.D.
Director
Immunization Service Division
National Immunization Program
STANDARD
GUIDE STARTS...
Introduction:
AFIX (Assessment, Feedback, Incentive, and eXchange) is a
continuous quality improvement tool that consists of:
1) assessment of the health care provider’s vaccination
coverage levels and immunization practices;
2) feedback of the results to the provider along with recommended
strategies to improve coverage levels;
3) motivating the provider through incentives to improve
vaccination coverage levels; and
4) exchanging health care information and resources necessary
to facilitate improvement. The AFIX methodology is
a comprehensive and effective tool for improving the
vaccination coverage levels and immunization practices
of health care providers. The improved outcomes produced by AFIX
through implementation of recommendations and best immunization
practices can be quantified through AFIX participation
over time. The efficacy of AFIX has been documented
in published and unpublished studies (see footnotes 1,
2, 3, 4. Several publications are
available on the AFIX website (www.cdc.gov/nip/afix).
Recently, several studies have been conducted to evaluate the implementation
of AFIX at the program level. Results
from these studies have shown a wide variation in the
implementation of AFIX activities with respect to methodology
and cost. Furthermore, during the V.F.C./AFIX Quarterly Conference Calls, participants
have expressed dissatisfaction
regarding the lack of clearly defined expectations from
C.D.C. Therefore,
the Clinic Provider Assessment
Workgroup (C.P.A.W.G.), consisting of AFIX coordinators
from state and urban immunization programs and C.D.C. staff,
developed standards to assist immunization grantees with
implementing and evaluating the AFIX component of
the V.F.C./AFIX initiative.
These standards are intended for use by the grantee program
staff overseeing the AFIX program. They are designed
to assist the AFIX or Assessment Coordinator/Supervisor
in implementing, managing, and evaluating an AFIX program.The
standards are specific enough so that grantees can design
their programs to fulfill the C.D.C. grant requirements,
yet they still offer flexibility so grantees can individualize
their programs for the specific conditions in their area.
A helpful companion document for these AFIX Standards
is the Core Elements of AFIX Training and Implementation.
The Core Elements document was created as a resource for
crafting the specifics of an AFIX visit and is to be
used for training AFIX staff on how to conduct an AFIX visit.
Together, these two tools will allow a grantee AFIX Coordinator/
Supervisor to manage and evaluate an AFIX Program at
a program level (using the AFIX Standards) and provide
guidelines for training staff new to AFIX (using the
Core Elements).
The AFIX Standards have been developed for three levels of
an AFIX Program. Standards for a Level 1 Program focus primarily
on the development and implementation of written protocols
and procedures and represent the basic components of
grant requirements. A Level 2 AFIX Program builds upon Level 1 written protocols
and procedures designed for its AFIX
activities. Standards for a Level 2 Program focus on improving existing protocols
and increasing activity, as well as developing plans for increasing objectives. A Level 3 AFIX Program
builds upon Levels 1 and 2 and is developing and implementing innovative strategies for improving
the AFIX process. Standards for a Level 3 Program focus on achieving and maintaining program objectives
and conducting evaluation activities to further improve the AFIX process.
It is expected that grantees may be at different levels
for one or more of the AFIX components. This manual and the
self assessment tool allow grantees to determine how
the overall AFIX program develops and matures in their
locales. The self-assessment tool can assist grantees with
future program planning, implementation and evaluation
of their AFIX programs.
Acknowledgements
The development of this document was made possible by the
hard work and dedication of the following individuals
and their organizations:
Terry Adams
Indiana State Health Department
Andrew Chilkatowsky
Division of Disease Control
Philadelphia Department of Public Health
Nathan Crawford
AFIX Coordinator
Oregon Department of Health Services
Nancy Fenlon
Program Operations Branch
Centers for Disease Control and Prevention
Holly Groom
Health Services Research and Evaluation Branch
Centers for Disease Control and Prevention
Amy Kirsch
Program Operations Branch
Centers for Disease Control and Prevention
Marcia Levin
V.F.C. Program Supervisor
Chicago Department of Public Health
Jacquelyn Ranches
Public Health Representative
New York State Department of Health
Rochester, N.Y. 14604
Shannon Stokley
Health Services Research and Evaluation Branch
Centers for Disease Control and Prevention
Atlanta, Georgia 30333
Betty Tran
Immunization Branch
California Department of Health Services
Berkeley, C.A. 94704
Nancy Fasano
Program Operations Branch
Centers for Disease Control and Prevention
Atlanta, Georgia 30333
Tasneem
Malik
Program
Operations Branch
Centers
for Disease Control and Prevention
Atlanta,
Georgia 30333
Program Operations Component
Principle
The program operations component provides a foundation for
implementing a fundamentally sound AFIX Program that
includes methods for planning, implementing and managing an AFIX
program. This component will also include clearly defined
procedures for training and guiding staff members on
AFIX protocols as the program develops over time.
Level 1 AFIX Program
A Level 1 AFIX Program should include the following Program
Operation standards in the written strategic plan:
1. Clearly defined measurable short and long-term objectives
for the AFIX program.
2. Clearly defined methods for evaluating progress at achieving
short and long-term objectives. Methods may include: definition
of key indicators; frequency of evaluating progress;
and time frame for achieving objectives.
3. Clearly defined methods for annually selecting at least
25 percent of enrolled V.F.C. providers to receive an AFIX
site visit. Methods should include how providers are prioritized
(for example, high-volume practice, never received an
AFIX visit, etc.) as well as defined criteria for selecting providers
in need of annual assessments. (marked with checkmark and pointer, for
explanation see footnote 5)
4. Clearly defined methods for identifying and recruiting
providers to participate in the AFIX program.
5. Written job descriptions for all staff involved with
the AFIX program.
6. Clearly defined procedures for AFIX staff members
to follow when issues beyond the scope of AFIX have been
discovered. These procedures should include which staff member
should be informed of which issue. For example, during
an AFIX visit, the field representative identifies a
possible case of fraud in the office and follows procedures
to notify an appropriate person for follow-up.
7. Clearly defined plan for training AFIX staff members. Plan should include a curriculum for training
new employees as well as periodic training updates for existing employees.
8. Clearly defined methods for supervising and monitoring
AFIX staff members’ progress at conducting the annual
AFIX site visits. Methods may include: definition of key indicators for assessing
progress and frequency of assessing progress.
9. Clearly defined methods for contacting outside agencies
and exploring the possibility of collaborating on quality
improvement activities and/or marketing AFIX.
Level 2 AFIX Program
A Level 2 AFIX Program should have achieved and implemented all standards
in Program Operations Level 1 as well as include the following standards in
the written strategic plan:
1. Annually review all AFIX related protocols and job descriptions
and update as needed.
2. Evaluate the feasibility of conducting V.F.C./AFIX combined
visits. If they are found to be effective, create a written
plan for making V.F.C./AFIX combined visits part of your
standard protocol. The plan should include:
a. A measurable objective (for example, increase combined
visits in calendar year 2005 by 15 percent)
b. Action steps for achieving the objective
c. Methods for reviewing the progress towards achieving
the objective
d. A time line for achieving the objective.
If the program determines combined visits are not appropriate
for their area, then a written statement should be included
in the AFIX protocol explaining why combined visits are
not appropriate.
3. Develop an agreed upon action plan with an outside agency(s)
to establish collaboration on quality improvement activities
and/or marketing AFIX.
Level 3 AFIX Program
A Level 3 AFIX Program should have achieved and implemented
all standards in Program Operations Levels 1 and 2 as
well as include the following standards in the written
strategic plan:
1. Develop and implement a written plan to increase the
percent of V.F.C. enrolled providers receiving an annual
AFIX visit to achieve the Healthy People 2010 assessment
goal. (see footnote 6)
2. Expand collaboration with other health care organizations,
such as managed care organizations, to develop methods
to reduce provider burden related to multiple record
reviews on preventive health services.
3. Assist providers who wish to conduct their own assessments
with strategies related to methodology, data collection,
analysis, and presentation with practice staff and the
immunization program.
4. Initiate collaboration with other programs within the department of health
to expand assessment activities beyond immunization. For example, in addition
to collecting immunization histories during the chart review, the field staff
also collects information on other health services such as lead screening,
tuberculosis screening, and/or dental screening. The purpose of this standard
is to expand the AFIX process to improve the utilization of other health care
services provided to children. For further information on Program Operations,
please refer to resources #1 (Sample AFIX Policies) and
#2 (Collaboration) in the Resources section at the end
of this document.
Assessment Component
Principle
Assessment provides a standardized method to collect and analyze
immunization data to estimate immunization coverage levels. Assessments conducted through
a site visit can provide valuable opportunities to assess
practice patterns that may encourage or unintentionally
discourage the delivery of immunizations to the practice’s
patient population.
Level 1 AFIX Program
A Level 1 AFIX Program should contain the following Assessment standards in
the written protocol and be available to AFIX field staff at all times:
1. Clearly defined procedures for contacting providers,
scheduling site visits, and documenting communication
with providers.
2. Clearly defined assessment parameters, including:
a. Assessment methodology (hybrid or standard)
b. Number of records to be included in the sample
c. Age range of children to be assessed
d. Inclusion Criteria/Active Patient (it is recommended
that the same
definition be used for all AFIX activities) (see footnote
7)
e. Immunization series to be assessed
f. Demographic data fields to be collected
g. Moved or gone elsewhere (M.O.G.E.)
3. Clearly defined methods for selecting a sample including
the persons responsible for pulling charts. Methods may include procedures for the following
scenarios:
a. Practice has fewer patients than the target sample size
b. Practice can provide an electronic list of patients
c. Practice cannot provide an electronic list of patients
4. Separate protocols for assessment procedures (for example,
Hybrid Assessment versus Standard Assessment) exist if
assessment methods differ among provider types (For example,
private versus public providers). If different assessment
procedures are used for different situations, each situation
should be described and included in the Assessment Protocol.
5. Clearly defined methods for supervising and monitoring
AFIX staff members’ implementation of the Assessment
Protocol.
A Level II AFIX Program should have achieved and implemented
all standards in Assessment Level I as well as contain
the following standards. This written protocol should
be available to AFIX field staff at all times:
1. Annually review assessment policies and staff activities
to ensure quality assessments are conducted.
2. Coordinate with immunization registry staff.
a. Establish a working relationship with the registry team
to ensure the registry can meet assessment needs.
b. Develop a written plan that explores the possibility
of abstracting registry data in place of chart data for
the assessment of immunization practices. (For more information,
refer to the Core Elements of AFIX Training and Implementation,
Appendix G.)
Level III AFIX Program
A Level III AFIX Program should have achieved and implemented
all standards in Assessment Levels I and II as well as
contain the following standards. This written protocol
should be available to AFIX field staff at all times:
1. Expand activities to include adolescents and adults with
written assessment policies for each age group.
2. Implement the use of registry data for assessment in
public and private provider offices.
a. Develop and implement written protocols on which provider
sites will be assessed using registry data.
b. Develop and implement written protocols for continuous
monitoring of quality of registry data used for assessments.
For further information on Assessments, please refer to resource
#3 (Assessment Methods) in the Resources section at the
end of this document.
------------------FOOTNOTES:
Footnote
1: Dietz, VJ,
management
factors associated with high vaccination coverage levels
in
Adolesc
Med 2000; 154: 184-189.
Footnote
2: LeBaron, CW, Chaney, M,
clinics,
1988-1994. JAMA 1997; 277: 631-635.
Footnote
3: LeBaron, CW, et-al, Changes in clinic vaccination
coverage after institution of measurement and feedback
in 4
states
and 2 cities. Arch. Pediatr Adolesc Med 1999; 153:
879-886.
Footnote
4:
feedback,
incentives, and exchange strategy. Pediatrics 1999;
103:6: 1218-1226.
Footnote
5: These two symbols are referenced in the Immunization
Program Operations Manual and are defined as:
Footnote 6:
(Healthy People 2010. Immunization Goals. Retrieved August
2, 2004 from http://www.healthypeople.gov/hpscripts/KeywordResult.asp?n345=345&Submit=Submit)
Footnote 7: Morrow, AL, Crews, RC, Carretta, HJ, Altaye, M, Finch,
AB, Sinn, JS. Effect of method of defining the active patient population on measured immunization rates in
predominately Medicaid or non-Medicaid practices. Pediatrics 2000; 106:1: 171-176.
Level II AFIX Program
-----------------
Feedback Component
Principle
Feedback is the process of informing immunization providers about
their performance in providing vaccines to a specifically
defined population. This process includes providing information on immunization
coverage levels for that provider and facilitating a
forum with provider staff to discuss how to improve their
immunization delivery system. Input from the provider and office staff is essential
to determine what changes are reasonable for the practice
to implement.
Level I AFIX Program
A Level I AFIX Program should contain the following Feedback
standards in the written protocol:
1. Clearly defined process for coordinating a Feedback session
which includes the following items:
a. Timing: Feedback sessions should occur at the convenience of the provider,
preferably within 10 working days of the assessment.(marked
with checkmark and pointer, for explanation see footnote 5)
b. Logistics: Feedback sessions should be a face-to-face meeting with provider
staff members unless there is a documented justification
for not conducting the session in person.(marked
with checkmark and pointer, for explanation see footnote 5)
c. Participants: Feedback sessions must include at least
one key staff member who has the ability to authorize
practice changes and ensure that agreed upon changes
take place. Sessions should also include as many additional
staff as possible.
2. Specific details regarding the presentation, documentation
and discussion of the following items during the Feedback
session:
a. Prioritize issues and identify at least 2 opportunities
for improvement
b. Any areas of strength related to the delivery of immunizations
c. Coverage levels for specific vaccination series and individual
antigens
d. Observations of office practices
e. Whether or not the provider staff agrees with your assessment
of their practice
f. The improvement strategies the provider staff believes
are feasible and relevant for the office to implement
3. Clearly defined process for developing a simple, written
quality improvement plan for the opportunities for improvement
that the provider agrees to implement. A signed copy
of this plan is to be kept by the provider and a copy
kept by the AFIX staff member. At a minimum, the plan
should include the following key items:
a. Opportunity for improvement on which to focus
b. Defined action steps for implementing the intervention
c. Responsible party for implementation
d. Date to implement intervention
4. Clearly defined list of items to leave with the provider
such as resource materials or informal incentives.
5. Clearly defined process for follow-up with the provider
and his/her staff to ensure the agreed upon commitments
are completed by the proposed date as outlined in the
quality improvement plan.
6. Clearly defined method for evaluation of feedback sessions,
which include having a supervisor attend a specified
proportion of each employee’s feedback visits.
Level II AFIX Program
A Level II AFIX Program should have achieved and implemented
all standards in Feedback Level I as well as include
the following standards in the written protocol:
1. Develop and implement clearly defined procedures for
AFIX field staff to promote continuous quality improvement
with providers and staff. For example, once providers
have demonstrated improvement in previously identified
areas, field staff will help providers identify new opportunities
for improvement.
2. Document all provider follow-up communication on proper
forms and give copies to the provider as appropriate.
3. Routinely update resource materials for providers.
Level III AFIX Program
A Level III AFIX Program should have achieved and
implemented all standards in Feedback Levels I and II
as well as include the following standards in the written
protocol:
1. Explore and pilot innovative methods for engaging providers
and presenting information in feedback sessions.
2. Provide ongoing assistance to providers who are not able
to document progress toward targeted areas of improvement.
3. Document the feedback policies and procedures for each
age group to be assessed (That is, adults, adolescents)
if the feedback procedure varies with the age group.
For further information on Feedback, please refer to resource
#4 (Feedback Sessions Checklist) and #5 (Opportunities
for Improvement documents) in the Resources section at
the end of this document.
Incentives Component
Principle
Incentives are used to motivate providers and practices to develop
more effective immunization delivery systems and ultimately
improve immunization coverage levels. Incentives promote change and reward achievement. Incentives may be formal or informal, as described
below, to assist or motivate a provider to make practice-based
changes and recognize improved performance.
Level I AFIX Program
A Level I AFIX Program should contain the following Incentives
standards in the written protocol:
1. Guidelines specifying that two informal incentives will
be offered during the feedback session.
2. Clearly defined list of options to use as informal incentives.
These incentives may include but are not limited to:
a. Printed immunization resources such as most current V.I.S.
statements and immunization schedule
b. Offer to provide educational in-services to the staff
on a variety of immunization topics
3. Clearly defined formal incentives that acknowledge providers
with improved or sustained high immunization coverage
levels; these formal incentives may include but are not
limited to: (marked with checkmark and pointer,
for explanation see footnote 5)
a. A letter of recognition signed by the governor or the
state health officer on official state letterhead
b. Public recognition of the provider with the greatest
immunization coverage level improvement at a state or
regional immunization conference
or similar forum
4. Clearly defined process describing how the formal incentives
are implemented. At
a minimum, the protocol must include:
a. Who is eligible to receive an award and/or recognition
b. How the award recipients are determined
Level II AFIX Program
A Level II AFIX Program should have achieved and implemented
all standards in Incentives Level I as well as contain
the following standards in the written protocol:
1. Document incentives offered by field staff and accepted
by providers. These informal incentives may include but
are not limited to:
a. Providing in-services on immunization issues to office
staff
b. Working with office on agreed upon immunization activities
2. Identify and utilize at least one potential partner to
assist with incentives. Supervisors should coordinate
activities with this partner.
3. Implement clearly defined incentives to assist low performing
offices in improving their immunization coverage levels.
The program policy for incentives should include the
following information:
a. Provider selection
b. Content
c. Participation incentives (if any)
d. Incentives for improved outcomes
Level III AFIX Program
A Level III AFIX Program should have achieved and implemented
all standards in Incentives Levels I & II as well
as contain the following standards in the written protocol:
1. Document the incentives policies and procedures for each
age group that will be assessed (That is, adults, adolescents)
if different incentives are used for different age groups.
eXchange
of Information Component
Principle
The exchange of Information is an opportunity to share best
practices with and among immunization providers. This
exchange can occur informally during the feedback session
or through formal avenues, which could include the identification
of an “immunization champion.” In addition, annual professional
gatherings such as public health conferences or state
medical association meetings provide opportunities to
exchange best practices in immunization services.
Level I AFIX Program
A Level I AFIX Program should contain the following eXchange
of Information standards in the written protocol:
1. List of specific information to exchange during the feedback
session, including but not limited to:
a. The current immunization schedule
b. The current V.I.S. statements
c. Additional immunization resources (For example, list
of credible immunization websites, schedule of immunization
satellite broadcast courses, etc.)
d. Pertinent standards for practice that are related to
the office’s strengths and opportunities for improvement
e. Interventions used in other practices with similar opportunities
for improvement
f. Information on national or state level immunization coverage
levels and goals
This standard differs from Incentive Component Standard #2
in that staff exchange information on how to obtain and
use the resource materials in their office.
2. Process used to promote the V.F.C./AFIX program at health
professional meetings or conferences. These meetings or conferences may include but
are not limited to: (marked with checkmark and pointer,
for explanation see footnote 5)
a. State or regional immunization conferences
b. State chapter meetings of medical associations such as
American Academy of Pediatrics (AAP), American Academy
of Family Physicians (AAFP), or American College of
Physicians
c. Meetings of health care insurers such as Medicaid, Medicare, health systems or managed care organizations (MCOs)
d. State or regional public health conferences
Level II AFIX Program
A Level II AFIX Program should have achieved and implemented
all standards in eXchange of Information Level I as well
as contain the following standards in the written protocol:
1. Document and review the interventions implemented by
providers to improve immunization coverage. Share the
outcomes with AFIX staff, providers, external partners
and other interested individuals or organizations. Utilize,
at a minimum, three different methods to exchange this
information on an annual basis, and maintain documentation
on how the information was exchanged. These methods may include but are not limited
to:
a. Informal discussions during feedback sessions, recorded
on the feedback checklist
b. Written information in a news article or a direct provider
mailing or fax
c. Formal presentations at local meetings, regional, state
or national conferences
d. Informal discussions during meetings with potential V.F.C.
providers or potential partners
2. Develop and implement a clearly defined, written plan
detailing the process for recruiting high performing
offices to become “immunization champions.” The “immunization
champion” will promote AFIX and quality improvement activities
to increase immunization coverage with peers. The strategic plan must include the following
components:
a. How to identify potential “immunization champions”
b. Recruitment methods
c. Methods to retain active “immunization champions”
d. Program oversight of activities
Level III AFIX Program
A Level III AFIX Program should have achieved and implemented
all standards in eXchange of Information Levels I and
II as well as contain the following standards in the
written protocol:
1. Utilize technologies to educate providers on immunizations
issues and strategies for improving the delivery of immunizations
and other preventive services. (That is, CDs, computer-based
training)
2. Develop and disseminate an annual summary report describing
immunization quality improvement activities to providers
and other health care agencies. The report content may
include but are not limited to:
a. Summary of visits conducted
b. Range of coverage levels
c. Number of providers with improved coverage levels
d. Case studies of specific providers who implemented new
strategies that improved their coverage levels
3. Share lessons learned by becoming a mentor to other state
and local immunization programs or by providing technical
assistance to the CPAWG committee.
4. Document the methods used to exchange information for
age group assessed if different methods are used with
the age groups.
Program Evaluation Component
Principle
Program evaluation is an important component to the V.F.C./AFIX
initiative. Just as AFIX is designed to help providers improve immunization
delivery practices, program evaluation will help improve
the implementation of AFIX. As a program matures, it
should develop research questions to determine how all
the components of the AFIX process can be improved.
Level I AFIX Program
A Level I AFIX Program should contain the following Evaluation
standards in the written protocol:
Standards
1. Utilize an electronic database to monitor site visit
activities. Programs may use the database developed by C.D.C. or create their
own. At a minimum, the database must be able to generate the summary information
that is requested in the Annual V.F.C. Management Survey.
2. Develop a written protocol for utilizing the electronic
database. The protocol should include:
a. Appropriate person(s) identified for entering information
into the database
b. Frequency of updating the database (e.g., weekly, monthly,
etc)
c. Procedures for transmitting data between the field and
the central office
d. Procedures for generating the information needed to complete
the V.F.C. Management Survey.
3. Submit Annual V.F.C. Management Survey to C.D.C. in appropriate
format by the designated due date.
4. Develop and implement procedures for conducting a process
evaluation of the AFIX Program. This may include:
a. Developing and assessing key indicators to evaluate if
internal processes are followed correctly by AFIX staff
b. Developing and assessing key indicators to evaluate providers’
satisfaction with the AFIX site visit in their practices
(example surveys can be found at the following address:
http://www.C.D.C.gov/nip/V.F.C./st_immz_proj/surveys/provider_ex/provider_examples.htm)
Level II AFIX Program
A Level II AFIX Program should have achieved and implemented
all standards in Evaluation Level I as well as contain
the following standards in the written protocol:
1. Develop methods to document and track the implementation
of interventions and outcomes.
2. Annually review the effectiveness of office based interventions.
Factors to consider in determining effectiveness are:
a. Change in coverage levels
b. Perceived ease of implementation of intervention and
time commitment
c. Amount of AFIX field staff time involved in intervention
d. Acceptance of intervention by office staff into daily
activities
e. Resources required for intervention to provider and immunization
program
Level III AFIX Program
A Level III AFIX Program should have achieved and implemented
all standards in Evaluation Levels I and II as well as
contain the following standards in the written protocol:
1. Develop, implement and document the impact of “immunization
champion” activities on improving immunization coverage
levels.
2. Implement written research and evaluation strategic plans
that include developing evaluation or research studies
focusing on the AFIX strategy. Include timelines for
starting and completing each study. Document a periodic review
and update of the evaluation and research strategic plans.
3. Periodically develop, implement, and evaluate programmatic
changes based on study findings.
a. Share evaluation findings with other state and local
immunization programs annually through at least one of
the following venues:
i. V.F.C./AFIX Quarterly Conference Calls
ii. C.D.C. /NIP AFIX website
iii. National Immunization Conference and/or Program Managers’
meeting
AFIX Standards Self-Assessment Tool
The following worksheets are designed as self-assessment
tools to assist grantees in identifying the level of
each AFIX component currently functioning within their
service areas. This self-assessment tool
allows each grantee to determine what components of its
AFIX program meet or exceed the standards for the different
levels. The self-assessment tool can be used as part of a comprehensive strategic
plan to build and improve the AFIX program at the local
or state level.
Self Assessment Operational Definitions
Level
Levels I, II and III represent the different levels
of AFIX program activities that can occur within each
component. A Level
I AFIX Program is a program that is systematically implementing
the basic grant requirements of the AFIX program. Standards
for a Level I Program focus primarily on the development
and initial implementation of written protocols and procedures. A Level II AFIX Program is a program that is actively
implementing the written protocols and procedures designed
for its AFIX activities. Standards for a Level II Program focus on improving
existing protocols and increasing activity, as well as
developing plans for increasing objectives. A Level III AFIX Program is an advanced program
that has been conducting AFIX activities for some time
and is starting to develop and implement innovative strategies
for improving the AFIX process. Standards for a Level III Program focus on achieving
and maintaining program objectives and conducting evaluation
activities to further improve the AFIX process.
Component and Standards
Addresses each of the 6 components: Program Operations,
Assessment, Feedback, Incentive, eXchange of information
and Evaluation. Lists each standard for
each level under the appropriate component.
Fully Met
The AFIX Program has fully implemented and possibly
exceeded the standard.
Partially Met
The standard is in the process of being implemented or
is implemented in part.
Could Meet
The standard could be implemented with low to
moderate resource investment, such as changes in policies and procedures,
and could be accomplished within the next 6 – 12 months.
Cannot Met
This standard would take a resource investment
beyond what is currently available to the program. Implementation of this standard is not planned
for at least 24 months in the future.
Next Steps
Action items or activities to strengthen or meet the standard.
Self-Assessment Worksheet for AFIX Standards
The AFIX Standards of Operation Workgroup has developed a
self-assessment worksheet that Immunization Programs
can use to determine the level at which each component
of their AFIX program is currently functioning. It
allows grantees to determine the components and standards
their AFIX Programs meet or exceed at each level. The
self-assessment tool can be used to develop a strategic
plan for individual AFIX programs.
Columns on spreadsheet:
Level
Component & Standard
Self-Assessment (? appropriate status): Fully
Met, Partially
Met, Could
Meet, Cannot
Meet
Next Steps
Rows under Level: 1, Component and Standard: Program Operations
Clearly defined measurable short and long-term objectives for
the AFIX program
Clearly defined methods for evaluating progress at achieving
short and long-term objectives. Methods may include: definition of key indicators;
frequency of evaluating progress; and time frame for
achieving objectives
Clearly defined methods for annually selecting at least 25 percent
of enrolled V.F.C. providers to receive an AFIX site
visit. Methods should include
how providers are prioritized (For example, high-volume
practice, never received an AFIX visit, etc.) as well
as define criteria for selecting providers in need of
annual assessments.
Clearly defined methods for identifying and recruiting providers
to participate in AFIX
Written job descriptions for all staff involved with the AFIX
program.
Clearly defined procedures for AFIX staff members to follow when
issues beyond the scope of AFIX have been discovered. These procedures should
include which staff member should be informed of which
issue. For example, during an AFIX visit, the field rep.
identifies a possible case of fraud in the office and
follows procedures to notify an appropriate person for
follow-up.
Clearly defined plan for training AFIX staff members. Plan should include a curriculum
for training new employees as well as periodic training
updates for existing employees.
Clearly defined methods for supervising and monitoring AFIX staff
members’ progress at conducting the annual AFIX site
visits. Methods may include: definition
of key indicators for assessing progress and frequency
of assessing progress.
Clearly defined methods for contacting outside agencies and exploring
the possibility of collaborating on quality improvement
activities and/or marketing AFIX.
Rows under Level: 2, Component and Standard: Program Operations
Annually
review all AFIX related protocols and job descriptions
and update as needed.
Evaluate
the feasibility of conducting V.F.C./AFIX combined visits.
If they are found to be effective create a written plan
for making V.F.C./AFIX combined visits part of your standard
protocol.
a.
Measurable objective (For example, Increase combined
visits in CY2005 by 15 percent)
b.
Action steps for achieving objective
c.
Methods for reviewing progress towards achieving objective
d.
Time line for achieving objectives
OR
If
the program does not think combined visits are appropriate
for their area, then a written statement should be included
in their material explaining why combined visits are
not appropriate.
Develop
an agreed upon action plan with outside agency(s) to
establish collaboration on Quality Improvement activities
and/or marketing AFIX
Rows
under Level: 3, Component and Standard: Program
Operations
Develop
and implement a written plan to increase the percent
of V.F.C. enrolled providers receiving an annual AFIX visit
to achieve the Healthy People 2010 assessment goal.
Expand
collaboration with other health care organizations, such
as managed care organizations, to develop methods to
reduce provider burden related to multiple record reviews
on preventive health services.
Assist
providers who wish to conduct their own assessments with
strategies related to methodology, data collection, analysis,
and presentation with practice staff and the immunization
program.
Initiate
collaboration with other programs within the department
of health to expand assessment activities beyond immunization.
For example, in addition to collecting immunization histories
during the chart review, the field staff also collects
information on other health services such as lead screening,
tuberculosis screening, and/or dental screening. The
purpose of this standard is to expand the AFIX process
to improve the utilization
of
other health care services provided to children.
Rows under Level: 1, Component and Standard: Assessment
Clearly defined procedures for contacting providers, scheduling site visits,
and documenting communication with providers.
Clearly defined assessment parameters:
Assessment methodology (hybrid, standard)
(a) # of records to be included in the sample
(b) Age range of children to be assessed
(c) Inclusion Criteria/Active Patient (it is recommended that the same
definition be used for all AFIX activities)
(d) Immunization series to be assessed
(e) Demographic data fields to be collected
(f) Moved or gone elsewhere (M.O.G.E.)
Clearly defined methods for selecting a sample, including the
persons responsible for pulling charts. Methods may include
procedures for the following scenarios:
(a) Practice has fewer patients than the target sample size
(b) Practice can provide an electronic list of pts. OR Practice
cannot provide an electronic list of pts.
Separate protocols for assessment procedures (for example, Hybrid
Assessment versus Standard Assessment) exist if assessment
methods differ among provider types (for example, private versus public).
If different assessment procedures are used for different
situations, each situation should be described and included in the Assessment Protocol.
Clearly defined methods for supervising and monitoring AFIX staff
members’ implementation of the Assessment Protocol.
Rows under Level: 2, Component and Standard: Assessment
Annually review assessment policies and staff activities to ensure
quality assessments are conducted.
Coordinate with immunization registry staff.
Establish a working relationship with the registry team to ensure
the registry can meet assessment needs.
Develop a written plan that explores the possibility of abstracting
registry data in place of chart data for the assessment
of immunization practices.
Rows under Level: 3, Component and Standard: Assessment
Expand activities to include adolescents and adults with written
assessment policies for each age group.
Implement the use of registry data for assessment in public and
private provider offices.
a. Develop and implement written protocols on which provider
sites will be assessed using registry data.
b. Develop and implement written protocols for continuous
monitoring of quality of registry data used for assessments.
Rows under Level: 1, Component and Standard: Feedback
Clearly defined process for coordinating a Feedback session which
includes the following items:
(a) Timing: Feedback sessions should occur at the convenience of the provider,
preferably within 10 working days of the assessment.
(b) Logistics: Feedback sessions should be a face-to-face meeting with provider
staff members unless there is a documented justification
for not conducting the session in person.
(c) Participants: Feedback sessions must include at least
one key staff member who has the ability to authorize
practice changes and ensure that agreed upon changes
take place. Sessions should also include as many additional
staff as possible.
Specific details regarding the presentation, documentation and
discussion of the following items during the Feedback
session:
(a) Prioritize issues and identify at least 2 opportunities
for improvement
(b) Any areas of strength related to the delivery of immunizations
(c) Coverage levels for specific vaccination series and individual
antigens
(d) Observations of office practices
(e) Whether or not the provider staff agrees with your assessment
of their practice
(f) The improvement strategies the provider staff believes are
feasible and relevant for the office to implement
Clearly defined process for developing a simple, written quality
improvement plan for the opportunities for improvement
that the provider agrees to implement. A signed copy
of this plan is to be kept by the provider and a copy
kept by the AFIX staff member. At a minimum, the plan
should include the following key items:
(a) Opportunity for improvement on which to focus
(b) Defined action steps for implementing the intervention
(c) Responsible party for implementation
(d) Date to implement interventio
Clearly defined list of items to leave with the provider such
as resource materials or informal incentives.
Clearly defined process for follow-up with the provider and his/her
staff to ensure the agreed upon commitments are completed
by the proposed date as outlined in the quality improvement
plan.
Clearly defined method for evaluation of feedback sessions, which
include having a supervisor attend a specified proportion
of each employee’s feedback visits.
Rows under Level: 3, Component and Standard: Feedback
Develop and implement clearly defined procedures for AFIX field
staff to promote continuous quality improvement with
providers and staff. For example, once providers have
demonstrated improvement in previously identified areas,
field staff will help providers identify new opportunities
for improvement.
Document all provider follow-up communication on proper forms
and give copies to the provider as appropriate.
Routinely update resource materials for providers.
Rows under Level: 3, Component and Standard: Feedback
Explore and pilot innovative methods for engaging providers and
presenting information in feedback sessions
Provide ongoing assistance to providers who are not able to document
progress toward targeted areas of improvement.
Document the feedback policies and procedures for each age group
to be assessed (that is, adults, adolescents) if the
feedback procedure varies with the age group.
Rows under Level: 1, Component and Standard: Incentives
Guidelines specifying that two informal incentives will be offered
during the feedback session.
Clearly defined list of options to use as informal incentives.
Examples may include:
(a) Printed immunization resources such as most current V.I.S.
statements and immunization schedule
(b) Offer to provide educational in-services to the staff
on a variety of immunization topic
Clearly defined formal incentives that acknowledge providers
with improved or sustained high immunization coverage
levels; Examples may include but are not limited to:
(a) A letter of recognition signed by the governor or the
state health officer on official letterhead
(b) Public recognition of the provider with the greatest
immunization coverage level improvement, such as at a
state or regional immunization conference
Clearly defined process describing how the formal incentives
are implemented; at a minimum, the protocol must include:
(a) Who is eligible to receive an award and/or recognition
(b) How the award recipients are determined
Rows under Level: 2, Component and Standard: Incentives
Document
incentives offered by field staff and accepted by providers.
These informal incentives may include but are not limited
to:
(a) Providing in-services on immunization issues to office
staff
(b) Working with office with agreed upon immunization
activities
Identify and utilize at least one potential partner to assist
with incentives. Supervisors should coordinate activities
with this partner.
Implement clearly defined incentives to assist low performing offices
in improving their immunization coverage levels. The
program policy for incentives should include the following
information:
(a) Provider selection
(b) Content
(c) Participation incentives
(d) Incentives for improved outcomes (if any)
Rows under Level: 3, Component and Standard: Incentives
Document the incentives policies and procedures for each age group
that will be assessed (that is, adults, adolescents)
if different incentives are used with the age groups.
Rows under Level: 1, Component and Standard: eXchange of Information
List of specific information to exchange during the feedback
session, including but not limited to:
(a) The current immunization schedule
(b) The current V.I.S. statements
(c) Additional immunization resources (for example, list of immunization
websites, schedule of immunization satellite broadcast
courses, etc)
(d) Pertinent standards for practice that are related to the office’s
strengths and opportunities for improvement
(e) Interventions used in other practices with similar opportunities for
improvement
(f) Information on national or state level immunization coverage levels
and goals
Process used to promote the V.F.C./AFIX program at health professional
meetings or conferences. These meetings or conferences may include but
are not limited to:
(a) State or regional immunization conferences
(b) State chapter meetings of medical associations such as A.A.P.,
A.A.F.P., or A.C.P.
(c) Meetings of health care insurers such as Medicaid, Medicare, health systems or M.C.O.
(d) State or regional public health conference
Rows under Level: 2, Component and Standard: eXchange of Information
Document and review the interventions implemented by providers
to improve immunization coverage. Share the outcomes
with AFIX staff, providers, external partners and other
interested individuals or organizations. Utilize, at
a minimum, three different methods to exchange this information
on an annual basis, and maintain documentation on how
the information was exchanged. These methods may include:
(a) Informal discussions during feedback sessions- recorded on the
feedback checklist
(b) Written information in a news article or a direct provider mailing
or fax
(c) Formal presentations at local meetings, regional, state or national
conferences
(d) Informal discussions during meetings with potential V.F.C. providers
or potential partners
Develop and implement a clearly defined, written plan detailing
the process for recruiting high performing offices to
become “immunization champions.” The “immunization champion”
will promote AFIX and quality improvement activities
to increase immunization coverage with peers. The strategic
plan must include the following components:
(a) How to identify potential “Immunization champions”
(b) Recruitment methods
(c) Methods to retain active “Immunization champions”
(d) Program oversight of activities
Rows under Level: 3, Component and Standard: eXchange of Information
Utilize technologies to educate providers on immunizations issues
and strategies for improving the delivery of immunizations
and other preventive services. (That is, C.D.s, computer-based
training)
Develop and disseminate an annual summary report describing immunization
quality improvement activities to providers and other
health care agencies. The report content may include
but are not limited to:
a. Summary of visits conducted
b. Range of coverage levels
c. Number of providers with improved coverage levels
d. Case studies of specific providers who implemented new
strategies that improved their coverage levels
Share lessons learned by becoming a mentor to other state and
local immunization programs or by providing technical
assistance to the Clinic Provider Assessment Workgroup
Document the methods used to exchange information for age group
assessed if different methods are used with the age groups.
Rows under Level: 1, Component and Standard: Program Evaluation
Utilize an electronic database to monitor site visit activities. Programs may use the database developed by C.D.C.
cdor create their own. At a minimum, the database must be able to generate
the summary information that is requested in the Annual
V.F.C. Management Survey.
Develop a written protocol for utilizing the electronic database. The protocol should include:
(a) Appropriate person(s) identified for entering information into the database
(b) Frequency of updating the database (for example, weekly, monthly, etc.)
(c) Procedures for transmitting data between the field and the central office
(d) Procedures for generating the information needed to complete the
V.F.C. Management Survey.
Submit Annual V.F.C. Management Survey to C.D.C. cin appropriate
format by the designated due date.
Develop and implement procedures for conducting a process evaluation
of the AFIX Program. This may include:
Developing and assessing key indicators to evaluate if internal
processes are followed correctly by AFIX staff
Developing and assessing key indicators to evaluate provider’s satisfaction
with the AFIX site visit in his/her practice (example surveys can be found at the following address: http://www.cdc.gov/nip/V.F.C./st_immz_proj/surveys/provider_ex/provider_examples.htm
Rows under Level: 2, Component and Standard: Program Evaluation
Develop methods to document and track the implementation of interventions
and outcomes.
Annually review the effectiveness of office based interventions. Factors to consider are:
(a) Change in coverage levels
(b) Perceived ease of implementation of intervention and time commitment
(c) Amount of AFIX field staff time involved
(d) Acceptance of intervention by office staff into daily activities
(e) Resources required for intervention to provider and immunization program
Rows under Level: 3, Component and Standard: Program Evaluation
Develop, implement and document the impact of “immunization champion”
activities on improving immunization coverage levels.
Implement written research and evaluation strategic plans that
include developing evaluation or research studies focusing
on the AFIX strategy. Include timelines for starting
and completing each study. Document a periodic review
and update of the evaluation and research strategic plans.
Periodically develop, implement, and evaluate programmatic changes
based on study findings.
Share evaluation findings with other state and local immunization
programs annually through at least one of the following
venues:
(a) V.F.C./AFIX Quarterly Conference Calls
(b) C.D.C./N.I.P. AFIX website
(c) National Immunization Conference and/or Program Managers’ meeting
AFIX RESOURCES
1. AFIX Policy Examples
2. Collaboration: Hints and Example
2.1. Using the Internet
2.2. Contacting organizations
2.3. Immunization Project collaboration example
3. Assessment Methods
3.1. Assessment method options
4. Feedback Sessions Checklist
5. Opportunities for Improvement
5.1. Intervention Handouts
5.1. Worksheet
Resource 1 AFIX Policy Examples
The following table of contents and written policy are provided
as examples of content and layout for the grantees. In
this policy example, the assessment standards addressed
are referenced in italics to illustrate how a written
policy can capture specific Level 1 Standards. These
are only examples and grantees should check with their
program to determine if there are specific requirements
for the formatting of policies within their agencies.
Grantees may also contact other grantees for additional
written policy examples.
AFIX Policy Manual Table of Contents
Policy Number: none
Policy Name: Overview of AFIX Project
Section: Overview
Policy Number: #1.0
Policy Name: AFIX Coordinator
Section: Program Operations
Policy Number: #1.1
Policy Name: AFIX Field Representative
Section: Program Operations
Policy Number: #1.2
Policy Name: AFIX Visit Assignments
Section: Program Operations
Policy Number: #1.3
Policy Name: Monthly Staff Visit Reports
Section: Program Operations
Policy Number: #1.4
Policy Name: Joint Supervisory Visits
Section: Program Operations
Policy Number: #1.5
Policy Name: New Employee Orientation
Section: Program Operations
Policy Number: #1.6
Policy Name: Employee Mentoring Program
Section: Program Operations
Policy Number: #1.7
Policy Name: Resources
Section: Program Operations
Policy Number: #1.8
Policy Name: Provider Selection
Section: Program Operations
Policy Number: #2.0
Policy Name: Scheduling an AFIX Visit
Section: Assessment
Policy Number: #2.1
Policy Name: Conducting the Assessment
Section: Assessment
Policy Number: #3.0
Policy Name: Conducting the Feedback Session
Section: Feedback
Policy Number: #3.1
Policy Name: Developing an Office based Quality Improvement Plan
Section: Feedback
Policy Number: #3.2
Policy Name: Post Feedback Follow up
Section: Feedback
Policy Number: #4.0
Policy Name: Utilization of Provider Incentives during the Feedback Session
Section: Incentives
Policy Number: #4.1
Policy Name: Recognition of Improved/High Coverage through Formal Incentives
Section: Incentives
Policy Number: #5.0
Policy Name: Exchange of Information during Feedback Session
Section: Exchange of Information
Policy Number: #5.1
Policy Name: Formal Exchange of Information
Section: Exchange of Information
Policy Number: #5.2
Policy Name: Promotion/Marketing of AFIX
Section: Exchange of Information
Policy Number: #6.0
Policy Name: V.F.C./AFIX Evaluation Software
Section: Program Evaluation
Policy Number: #6.1
Policy Name: Provider Satisfaction Survey
Section: Program Evaluation
Policy Number: (fill in blank) Policy
Name: (fill in blank)
Section: (fill in blank)
Policy Number: 2.1 Conducting the Assessment
Purpose: To provide a standardized assessment policy for all staff
and contractors who conduct AFIX quality improvement
activities in both public and private health care settings.
Policy: The following assessment policy will be implemented
as written by all staff and contractors conducting AFIX
quality improvement activities.
1. Provider Selection for participation in the AFIX project
will be based on the criteria documented in policy #
1.8: Provider Selection. (Addresses Program Operation Standards 3 and 4)
2. Provider will be contacted and AFIX visit scheduled according
to policy # 2.0: Scheduling an AFIX visit. (Addresses
Assessment Standard 1)
3. All staff will utilize the following assessment parameters
during manual chart assessments:
a. Standard CASA with a 50 record sample (If office has
50 or fewer children in age range, enter all children
in the age range into the assessment.)
b. Sample age range is 24 through 35 months of age as of
assessment date.
c. For the purposes of the AFIX project, Moved or Gone Elsewhere
(M.O.G.E.) will be defined as any child in the sample
with any one of the following types of documentation in the medical record before 24 months of age:
* Child transferred to a new practice as evidenced by a
provider note or request for records
* A mailed reminder card sent to the parents or guardians
returned by the post office with no new local forwarding
address
* A documented telephone or other contact indicating that
the family is no longer at the address of record
d. An active patient will be defined as any child with one
or more well-child visits since birth with no documentation
of being a M.O.G.E.
e. For the purposes of the AFIX project, the following demographic
variables will be collected for each child in the sample:
* Last name
* First name
* Zip code
* Date of birth
* V.F.C. eligibility
* V.F.C. documentation
f. For the purposes of the AFIX project, the following immunization
series will be measured for up-to-date status at 24 months:
* 4DTaP-3Polio-1MMR-3Hib-3HepB- 1Varicella (Addresses Assessment Standard 2)
4. All staff will use the following sampling guidelines
to pull the children in the sample for the assessment
component, if the population is greater
than 50:
* If provider is able to generate list of all patients
24 through 35 months of age and provide the list to you
7 to 10 working days before the visit date, use a random
numbers table to generate the list of 50 children to
be sampled and fax sample list back to the office no
later than 5 working days prior to visit date (refer
to Core Elements of AFIX Training
and Implementation for information on sampling
methods.)
* If provider is unable to generate a list of children
but is willing to allow you to pull the charts, the Shelf
Method will be used as the sampling methodology. (This
method is described in more detail in Appendix
F of the Core Elements of AFIX Training and Implementation.)
* If the provider is unable to generate a list of children
and is not willing to allow you to pull the charts then
instruct the office to pull the charts using the Shelf
Method.
* If the provider is unable to generate a list of children,
is not willing to allow you to pull the charts, and is
unwilling to utilize the shelf method, then instruct
the office to pull the charts using the Appointment Book.
(This method is described in more detail in Appendix
F of the Core Elements of AFIX Training and Implementation.)
(Addresses Assessment Standard 3)
5. Enter dose data from charts into CASA
6. After the data are entered, at minimum review the following
CASA reports to determine strengths and areas of opportunities:
Diagnostic Report
CASA Summary Report
Single Antigen Report
7. All new staff and new contract staff will participate
in a supervised assessment visit between day 60 and 120
of employment to ensure that new staff (health department
and contract) are implementing the assessment component
of AFIX appropriately. (Addresses Assessment Standard 5)
8. Prior to incumbent staff annual performance review, staff
will participate in a supervised assessment visit to
ensure that staff members are implementing the assessment
component of AFIX appropriately. (Addresses Assessment Standard
5)
Authorizing Signature: (signature goes here)
Date Implemented: (date goes here)
Annual Review Date: (date goes here)
Revision Date: (date goes here)
Note: Assessment Standard #4 not applicable
Resource 2: Getting Started with Collaboration: Hints and Examples
The following helpful hints section and Power Point slides
are provided as examples of how to start collaborating
with outside organizations on AFIX activities. The helpful hints section provides the user with
ideas on how to identify potential collaborators, how
to organize your first contact and how to develop an
agenda for the first face-to-face meeting with a potential
collaborator.
The Power Point slides illustrate how one project collaborated
with a large insurer in the state to promote AFIX and
the lessons learned from the initial collaboration experience.
Resource 2.1 Using the Internet to Learn More about Potential Collaborators
1. Use your network of immunization contacts to identify
health care organizations that serve the population of
interest and may be strong candidates for collaboration
such as:
– Medicaid/Medicare
– Commercial Insurers in your program area
– Physician organizations
– American Academy of Pediatrics website has links
to state chapter websites
2. If possible, locate and visit the website(s) of a potential collaborator(s)
3. Identify shared goals or common activities discussed
on the website
– Some key terms that might lead to potential AFIX
collaboration include:
– Children’s Services
– Performance Measures
– Clinical Guidelines
– Preventive Services
– Clinical Indicators
– Provider Services
– Immunizations
– Quality Improvement
– Medical Services
– Well-Baby Services
4. Review content of website in these areas to determine
shared goals or common activities.
5. Answer the following question: “Could the AFIX process
potentially assist this organization’s activities?” If
you answer yes, identify a potential contact person to
discuss possible collaboration opportunities.
Resource 2.2 Contacting Organizations Regarding Collaboration
1. It is always helpful to have an outline of key points
on why collaboration would be beneficial to both organizations
when contacting potential collaborators.
2. When preparing the outline focus on a positive win-win
scenario. Strategically address the benefits to the potential
collaborator near the beginning of your conversation. When developing your key points, use terminology
from the website to support your idea/offer of collaboration. For example, one insurance website (identifiers
were removed) stated the following commitment to childhood
immunizations and interventions for improving coverage
levels:
Childhood Immunizations
* H.M.O. in State (fill in state name) is attempting to
increase the number of children receiving age-appropriate
immunizations.
* Immunization schedules are published in member newsletters.
* Postcards are sent to parents of children who are 16
months and 20 months old about preventive exams and immunizations.
* Physicians and other professional providers receive updated
immunization schedules.
Several other areas in this website mentioned the importance
of childhood immunization based on this information;
it appears this organization would make an excellent
candidate for collaborating with the state’s AFIX activities.
3. When organizing your collaboration call, use the website
information to engage the organization in a collaborative
discussion using their quality improvement commitment
to childhood immunization coverage as an ice breaker. The introduction/background should mention the
organization’s commitment and active interventions to
enrolled members and contracted providers to improve
childhood immunization coverage levels. A possible collaboration
call could start something like the following example:
“I recently visited your Managed Care Organization’s
(M.C.O.) website and was pleased to read about your commitment
to quality improvement activities and especially about
your interventions focusing on childhood immunizations. As you may be aware, the
state’s immunization program actively works with both
public and private health care providers to improve childhood
immunizations coverage levels in the state. After visiting your company’s
website, I have a few ideas on how we can possibly work
together to improve immunization coverage levels in your
contracted provider offices in a cost effective manner
for your organization. Can we schedule a time to meet to talk about these
ideas?”
4.
Once you have scheduled a meeting date, the next activity
is to organize your thoughts on collaborative opportunities. One way to organize your
thoughts is through the development of a meeting agenda. Below is an example of a simple draft agenda for
this type of meeting:
Agenda
M.C.O.-AFIX Collaboration Opportunities
1. Purpose and Background
2. Collaboration Opportunities
3. Benefits to M.C.O. and Immunization Program
4. Discussion
5. Next Steps/Follow-up/Timeline
5. It is a good idea to further develop the agenda with
bullet points of key ideas/concepts to discuss under
each agenda item for your personal reference during the
meeting. For example,
during Purpose and Background some key concepts for discussion
include:
• Overview of V.F.C./AFIX Initiative
• Shared populations
• Common quality improvement goal
Repeat this process with each agenda topic but be mindful of
the time limit for this meeting and keep the discussion
focused on the main concepts.
6. An example of an advanced agenda:
Agenda
M.C.O.-AFIX
Collaboration Opportunities
1. Purpose and Background
• Overview of V.F.C./AFIX Initiative
• Shared populations
• Common quality improvement goals
2. Collaboration Opportunities
• Simple Opportunities (Short term, minimal planning)
- Website resources (current schedule, web links)
- Clinical guideline development/review
- Provider newsletter
- Member newsletter
- Office manager forum
- External Provider workshop
- MCO staff education (medical services/provider services/member services)
- Immunization resources through health department/C.D.C.
• Complex Opportunities (long term)
- Provider referral to health department for AFIX services
- Participation in AFIX with certain results would substitute for certain M.C.O. quality
improvement activities
- Use a multi-focused AFIX process to improve other M.C.O. quality indicators along with immunizations to
decrease provider burden related to record reviews
3. Benefits to M.C.O. and Immunization Program
• M.C.O. Benefits
- Free expert information on Immunizations for a variety of Q.I. activities
- Process in place to assist providers struggling with low immunization
coverage levels by referring to health department for AFIX services
- Improve H.E.D.I.S. scores
- Potential to decrease provider burden related Q.I. activities and
decrease M.C.O. cost around Q.I. activities
• Health Department Benefits
- New opportunity to promote AFIX activities
- Support from health insurer for AFIX activities
- Access to private providers
4. Discussion
• Are there opportunities to collaborate short term and/or possibly long term?
5. Next Steps/Follow-up/Timeline
The meeting’s time schedule will not allow you to discuss
all the potential collaboration opportunities in depth.
A good strategy is to focus on 3 to 4 short term and
simple activities and obtain agreement on those activities. You may briefly discuss possible ideas for long-term,
complex collaboration activities depending on the organization’s
response to the short-term activities.
Resource 2.3 - Immunization Project Collaboration Example
Slide Presentation:
Slide 1:
Slide Title: AFIX Collaboration Between Health Plan and Health Department: Creating a Template for Quality
Marcia H. Levin, M.P.H.
Chicago Department of Public Health
Carol Wilhoit, M.D., M.S.
Blue Cross Blue Shield of Illinois
Janet Larsen, M.A.
I.D.P.H.
Slide 2:
Slide Title: H.M.O. of B.C.B.S.I.L.
Slide 3:
Slide title: Development of the Collaboration
Slide 4:
Slide title: Project Methodology- Health Plan Perspective
Slide 5:
Slide title: BCBSIL Project Timeline
November 2001 - Project added to 2002 contract between B.C.B.S.I.L.
and M.G./I.P.A., with details in contract attachment
January 1, 2002 - March 15, 2002 - Doctors submitted
Intent to Participate form
April 2002 - B.C.B.S.I..L. sent database with M.D. list
to I.D.P.H.
July 1, 2001 - December 31, 2002 - AFIX assessments and
feedback sessions were done by I.D.P.H., C.C.D.P.H. and
C.D.P.H.
By February 15, 2003 - M.G./I.P.A. submitted participation
summary, copies of AFIX assessment, committee minutes,
and corrective action plans
March 2003 - B.C.B.S.I.L. payment due to M.G./I.P.A.
Slide 6:
Slide title: Project Methodology- Health Department Perspective
Slide 7: Slide title: Impact of Project
Slide 8:
Slide title: Examples of Corrective Action Plans Required for
Practices with 24-month Rates less than 60 percent
Slide 9:
Slide title: Examples of Corrective Action Plans
Slide 10: Slide title: The Collaboration Was Positive: Health Department Perspective
Slide 11:
Slide title: Corrective Action Plan Feedback
Slide 12:
Slide title: The Collaboration Was Positive: Health Department Perspective
Slide 13:
Slide title: The Collaboration Was Positive: BCBSIL Perspective
Slide 14:
Slide title: Barriers and Challenges
Slide 15:
Slide title: Conclusions