CORONAVIRUS (COVID-19) RESOURCE CENTER Read More

Bismarck-Burleigh Public Health

State: ND Type: Promising Practice Year: 2019

Bismarck-Burleigh Public Health (BBPH) participated in a national quality improvement project that was guided by the National Improvement Partnership Network (NIPN), Academic Pediatric Association (APA), and the Continuity Research Project (CORNET) for the Cohort 3 project time period from January, 2017 through October, 2017 in an effort to increase Human papillomavirus (HPV) vaccination rates and reduce missed opportunities of the HPV vaccine. Monthly data collection through BBPH's electronic health record (EHR) system was completed by project members. Subsequently, project members ran data reports from the North Dakota Immunization Information System (NDIIS) for adolescents aged 11-13 years that were due to receive the HPV vaccine. The NDIIS was also utilized daily as an access point for provider-prompts that were assessed for every adolescent aged 11-17 years that had an appointment at BBPH. Reminder-recall letters with best-practice education were mailed to several hundred adolescents to promote community education of the HPV vaccine and a prompt parents and guardians to obtain the vaccine for their children.

  Keywords: HPV vaccine, reminder-recall, provider-prompt

https://www.bismarcknd.gov/95/Public-Health

The City of Bismarck and Burleigh County are continuously experiencing growth and the effects of an increasing population.  The estimated population of Burleigh County as of June 1, 2018 is 96,990 which is a .32% increase from July 1, 2017 (96,684) and an increase of 19% from the 2010 US Census Bureau population of 81,308.  The Estimated population of the City of Bismarck as of June 1, 2018 is 74,391 an increase of .45% from July 1, 2017 (74,060) and an increase of 21% from the 2010 US Census Bureau estimated population of 61,272. With this increasing population and change in demographics, public health services are in high demand. 

A total of six BBPH staff were involved in the Cohort 3 practice project and took part in monthly data collection, webinars, and practice project requirements. Overall, five registered nurses and one office manager made up Cohort 3 practice project team and directed several activity strategies that were subsequently implemented into practice at BBPH. All registered nurses employed at BBPH were made aware of the practice project as well as office staff to ensure buy-in of the project and a universal understanding of the implementation strategies.

The first strategy that was implemented as part of the Cohort 3 practice project was a provider-prompt system. Front office staff would pull a list of client's that were on the schedule to be seen in the clinic on a daily basis. Then, they would access each client's immunization record from the NDIIS and print a copy for a registered nurse to review. Every adolescent aged 11-17 years was assessed for HPV vaccination status at every clinic visit, even if they were not scheduled to receive immunizations. If the client was eligible to receive HPV vaccine, it was offered by registered nurses and documented in the electronic health record.

Custom fields were developed in the EHR to document the following information at every adolescent visit: HPV eligibility status, provider-prompt utilization, previous doses of HPV given, if HPV was given at date of service, and a reason for not administering HPV vaccine. A monthly report was completed and assessed for any failure to comply with HPV custom field EHR documentation. If documentation was not completed, staff were consulted for reasoning and reminders were sent to ensure future compliance was garnered.

An additional strategy of reminder-recall was implemented as a way to both communicate with the public about the HPV vaccine, and prompt parents and guardians to obtain the HPV vaccine for their children. At the start of the Cohort 3 practice project, team members completed an extensive assessment of all adolescents that were assigned to BBPH in the NDIIS and were due to receive HPV vaccine. Letters detailing the importance of the HPV vaccine and an explanation of why and when it is needed were sent to all eligible adolescents. Documentation of these activities was also completed in each client's chart in BBPH's EHR. By documenting that reminder-recall letters were mailed, BBPH could track if the letters were successful in improving vaccination rates. 

Cohort 3 practice project team members received valuable education from partners at NIPN, APA, and CORNET through monthly webinars. Webinar topics ranged from quality improvement, improving provider recommendations, and reducing missed opportunities, to specific HPV vaccine information, and office policies management. Practice project team members found the education surrounding difficult parents or guardians showing resistance to the HPV vaccine the most helpful throughout the webinar series'. The most common reason for clients not receiving the HPV vaccine at BBPH is due to parental/guardian resistance and refusal.


Model Practice Program: Bismarck-Burleigh Public Health

City of Bismarck

Bismarck, ND 58504

Director: Renae Moch, MBA, FACMPE

Project Lead: Theresa Schmidt, RN, BSN

Application Author: Betsy Kanz, RN, BSN

Bismarck-Burleigh Public Health Director
Renae Moch, MBA, FACMPE
rmoch@bismarcknd.gov
(701) 355-1541

Bismarck-Burleigh Public Health Nurse Manager
Theresa Schmidt, RN, BSN
tschmidt@bismarcknd.gov
(701) 355-1578


Responsiveness and Innovation

As with any new process, the initiation of the Cohort 3 practice project proved to be a challenge for team members and other BBPH staff. It took several weeks and many reminders for staff to regularly review provider-prompts for every client aged 11-17 years. Also, the reminder-recall letters and documentation were an astronomical time constraint for staff due to the large volume of clients served through BBPH. Furthermore, staff showed resistance to the addition of the HPV custom tab in the EHR. The most common reason why staff were resistant to the HPV custom tab was because of the additional time it took to complete. After several weeks and many verbal and electronic reminders, staff complied with the additional charting. A weekly report was accessed through the EHR to verify staff compliance with completing the HPV custom tab, and staff were reminded to complete charting if they had not already done so. After several months, the number of missed HPV tab documentation or provider-prompt utilization went from an average of 5, to 0 or 1.

Several innovations took place during the Cohort 3 practice project that improved BBPH's quality of care that was provided to adolescents who were eligible to receive HPV vaccine. All adolescents aged 11-17 years were provided with a client-centered appointment, where their immunization records were thoroughly reviewed. Many adolescents were caught up with required immunizations for school and additional, life-saving vaccines like HPV, Meningococcal B, Hepatitis A, and Influenza because of strong provider recommendations.

One innovation that was already in place prior to the Cohort 3 practice project included standing orders for all Advisory Committee on Immunization Practice-recommended vaccines. Since this strategy was already in place, nurses could administer any immunization that an adolescent was due to receive during their appointment at BBPH. Many adolescents were provided with HPV vaccine and were provided with other vaccines they were missing.

The greatest innovations that took place during the Cohort 3 practice project were the work done on data collection and charting in the EHR. Staff were able to see the progress they were making in improving HPV vaccination rates. Also, they could monitor the reduction in missed opportunities for vaccines. Furthermore, staff could see the pay-off their work had accomplished in overall adolescent immunization rates for clients assigned to BBPH.

Local Health Department (LHD) and Community Collaboration and Implementation Strategy

The Cohort 3 practice project lead presented BBPH's strategies for improving HPV vaccination rates and reducing missed opportunities to the North Dakota National Association of County and City Health Officials during a meeting. Also, the Cohort 3 practice project team was awarded the North Dakota Public Health Team of the Year by the North Dakota Public Health Association (NDPHA) for their work with improving HPV vaccination rates, knowledge, and education for adolescents in the community.

Every other health department and practice site that attended both the NDPHA conference and the NACCHO presentation were educated on BBPH's strategies to improve HPV vaccination rates and reduce missed opportunities. The strategies implemented during the Cohort 3 practice project apply to any practice site or local public health unit that offer adolescent vaccines. BBPH offered education to community partners about the struggles and successes of the Cohort 3 practice project.

Evaluation

Overall, staff that took part in the Cohort 3 practice project found it helpful in reducing missed opportunities for vaccines and improving HPV vaccination rates among adolescents aged 11-17 years. The monthly data reports that were completed by NIPN were invaluable to staff at BBPH as it marked progress and was a reminder of the work that was being accomplished by staff.

The biggest challenge that practice project team members faced was sending reminder-recall letters. The time that was required to send out letters to all of the adolescents that were assigned to BBPH was more than initially anticipated. Also, the return on investment was low in relation to the time allotted to complete the activity.

 A minimal number of clients responded to the reminder-recall letters and actually obtained HPV vaccination as a result. Staff were not able to monitor what clients went to other clinics in the community to receive HPV vaccination. Nonetheless, adolescents and their parents/guardians were provided with evidence-based education related to HPV and the HPV vaccine.

Although some challenges occurred during the project, the overall success in improving HPV vaccination rates and reducing missed opportunities was unfathomable. During the Cohort 3 practice project, BBPH reduced missed opportunities by 86%.

The practice project team also saw the overall percentage of clients aged 11-17 that initiated HPV vaccine increase by 40%. This percent increase is considered a major success for the Cohort 3 practice project team. The practice project team attributes the increase in initiation of series to routine utilization of provider prompting, stronger provider recommendations, staff accountability, and reminder-recall letters..

Sustainability

BBPH provides vaccinations for all ages and has the ability to bill most 3rd party payers and is a partner with the North Dakota Department of Health and federal Vaccines for Children Program. Standing orders for immunizations are reviewed every year and signed by the medical provider for BBPH. Additionally, registered nurses continue to provide strong recommendations for the HPV vaccine to parents and adolescents.

Registered nurses at BBPH have received education related to the importance of HPV vaccine, completing documentation in the EHR, and utilizing provider-prompts for all clinic appointments. BBPH has also partnered with the North Dakota Department of Health in an effort to increase HPV vaccination initiation and completion of series. Data reports continue to be accessed and reviewed monthly to verify compliance of HPV custom field documentation in the EHR. Staff at BBPH value the historical, present, and future partnership with NIPN, CORNET, and APA in an effort to increase HPV education and vaccination rates.




Local Health Department (LHD) and Community Collaboration and Implementation Strategy

The Cohort 3 practice project lead presented BBPH's strategies for improving HPV vaccination rates and reducing missed opportunities to the North Dakota National Association of County and City Health Officials during a meeting. Also, the Cohort 3 practice project team was awarded the North Dakota Public Health Team of the Year by the North Dakota Public Health Association (NDPHA) for their work with improving HPV vaccination rates, knowledge, and education for adolescents in the community.

Every other health department and practice site that attended both the NDPHA conference and the NACCHO presentation were educated on BBPH's strategies to improve HPV vaccination rates and reduce missed opportunities. The strategies implemented during the Cohort 3 practice project apply to any practice site or local public health unit that offer adolescent vaccines. BBPH offered education to community partners about the struggles and successes of the Cohort 3 practice project.

Overall, staff that took part in the Cohort 3 practice project found it helpful in reducing missed opportunities for vaccines and improving HPV vaccination rates among adolescents aged 11-17 years. The monthly data reports that were completed by NIPN were invaluable to staff at BBPH as it marked progress and was a reminder of the work that was being accomplished by staff.

The biggest challenge that practice project team members faced was sending reminder-recall letters. The time that was required to send out letters to all of the adolescents that were assigned to BBPH was more than initially anticipated. Also, the return on investment was low in relation to the time allotted to complete the activity.

 A minimal number of clients responded to the reminder-recall letters and actually obtained HPV vaccination as a result. Staff were not able to monitor what clients went to other clinics in the community to receive HPV vaccination. Nonetheless, adolescents and their parents/guardians were provided with evidence-based education related to HPV and the HPV vaccine.

Although some challenges occurred during the project, the overall success in improving HPV vaccination rates and reducing missed opportunities was unfathomable. During the Cohort 3 practice project, BBPH reduced missed opportunities by 86%.

The practice project team also saw the overall percentage of clients aged 11-17 that initiated HPV vaccine increase by 40%. This percent increase is considered a major success for the Cohort 3 practice project team. The practice project team attributes the increase in initiation of series to routine utilization of provider prompting, stronger provider recommendations, staff accountability, and reminder-recall letters.








Sustainability

BBPH provides vaccinations for all ages and has the ability to bill most 3rd party payers and is a partner with the North Dakota Department of Health and federal Vaccines for Children Program. Standing orders for immunizations are reviewed every year and signed by the medical provider for BBPH. Additionally, registered nurses continue to provide strong recommendations for the HPV vaccine to parents and adolescents.

Registered nurses at BBPH have received education related to the importance of HPV vaccine, completing documentation in the EHR, and utilizing provider-prompts for all clinic appointments. BBPH has also partnered with the North Dakota Department of Health in an effort to increase HPV vaccination initiation and completion of series. Data reports continue to be accessed and reviewed monthly to verify compliance of HPV custom field documentation in the EHR. Staff at BBPH value the historical, present, and future partnership with NIPN, CORNET, and APA in an effort to increase HPV education and vaccination rates.

E-Mail from NACCHO