Running head: IMPROVING STAFF KNOWLEDGE AND SKILLS ON IMMUNIZATION

Organizational Assessment:
Improving Staff Knowledge and Skills on Immunization
at Skagit Regional Clinics
N. Tabara Khan, RN, Josefina Turnek, RN, Kathryn Lewandowsky, RN
Western Washington University RN-to-BSN Program
NURS 422 Organizational Change for Quality and Safety in Healthcare
December 2, 2016

IMPROVING STAFF KNOWLEDGE AND SKILLS ON IMMUNIZATION

Introduction
Immunization prevents between two to three million deaths annually in all age groups
from diphtheria, tetanus, pertussis, and measles (World Health Organization, [WHO], n.d.). It
was through immunizations that smallpox was eradicated. The WHO estimates that one in four
children are not immunized and about three million people die annually from vaccine
preventable diseases (Cameron, 2009). Recommendations and guidelines are provided by the
Centers for Disease Control and Prevention [CDC] according to the different age groups
(Immunization Schedules, n.d.), however the CDC does not set the immunization requirement
for schools and childcare centers in every state (State Vaccination Requirements, n.d.). The
immunization requirements and immunization schedules are based on the recommendations of
the Advisory Committee on Immunization Practices (ACIP) who provide advice and guidance
to the Director of the CDC regarding use of vaccines and related agents for effective control of
vaccine-preventable diseases in the civilian population of the United States (ACIP Charter,
2016, p.1).
The vaccine coordinator at Skagit Regional Clinic (SRC) has given our practice
experience group the privilege of restructuring the clinics immunization class. Our group is
revamping this class in order to improve new employees ability to learn the materials necessary
in providing safe, effective immunizations to their clients while avoiding unnecessary
complications. In restructuring this class, our goal is to reduce redundancies, restructure class
contents in a more logical order and incorporate web links to facility system wide immunization
policies and protocols along with also national websites that provide evidence-based
immunization resources. We also hope to reduce paper consumption by the system and improve
employees ability to locate immunization resources in their day-to-day workflow. We felt it is

IMPROVING STAFF KNOWLEDGE AND SKILLS ON IMMUNIZATION

important to include web links for additional educational materials necessary to properly store
and administer immunizations according to the CDC guidelines and also Washington State
Schools guidelines for school entry requirement (School and Child Care Immunizations, n.d.). It
will also touch the SRCs NextGen current Electronic Medical Record (EMR) documentation
system so that all new SRC employees will be confident in how to properly document all of the
required information within their EMR.
Immunization is the most successful and cost-effective public health intervention
throughout the world. It has been proven to be the most successful prevention against vaccine
preventable infectious diseases (Immunization & Child Profile Office, n.d.) especially in children
(WHO, n.d.). Due to the fact that their immune systems are still in the process of developing, it is
crucial that this vulnerable group get immunized against vaccine preventable diseases. The
Washington State Schools have clear requirements that all children according to age have
received a series of vaccinations against infectious diseases prior to school entry (School and
Child Care Immunization, n.d.). Unfortunately, not all children have received their required
immunizations. Some children are exempt for several reasons such as medical, religious or
philosophical (State Vaccination Requirements, n.d.), while others may not have received the
immunizations as correctly outlined in the Washington Department of Health [WA. DOH] and
CDC guidelines. These children who are not immunized are at risk for exposure to vaccine
preventable infectious diseases. They then may also put other vulnerable people in the
community at risk for acquiring vaccine preventable infectious diseases including the very
young, the very old, and those who have chronic conditions or are immunocompromised.

IMPROVING STAFF KNOWLEDGE AND SKILLS ON IMMUNIZATION

Change Theory
Change sometimes is necessary for any organization to improve or adopt new or better
ways of doing things. Change can be challenging and may make some people feel uncomfortable
or uneasy. On the other hand, some people may see change as an opportunity for improvement or
as a sign of hope. The nursing profession always strives for excellence to provide cost effective
patient care based on evidence and because of that, quality indicators have been chosen to
adequately assess quality improvement. In order to make the necessary changes, an organization
needs to have a solid plan. Several theorists have attempted to explain the proper way of
approaching change and one of them is Kurt Lewin, who was a physicist and a social scientist.
His most influential theory is what is known as the Lewins Change Theory which he
developed in the 1940s and is still being used today by many businesses and organizations. It is
a three-staged model of change known as the unfreezing-change-refreeze model (Mind Tools
Editorial Team, n.d.). This model promotes letting go of old, formed, counterproductive habits,
replacing them with new productive practices and then making these new productive practices
the new normal or the standard way of doing things.
The first stage is the unfreezing stage which Lewin called the quasi-stationary
equilibria. This stage uses a force field analysis to assess the driving and restraining forces in
order to reach the desired goal or outcome. The second stage, which is the change stage, is for
individuals to adapt the new ways of doing things and work within the change. The model is
completed through the third stage, or the refreezing stage. It is completed when the new way
of doing things is now the new norm or standard way of doing things (Sare & Ogilvie, 2010).

IMPROVING STAFF KNOWLEDGE AND SKILLS ON IMMUNIZATION

Lewins Change Theory addresses what we are trying to accomplish in restructuring the
immunization class in Skagit Regional Clinics. We have several goals to accomplish in this
project. In the unfreezing stage, we want the new employees to become confident in their skills
in order to give vaccinations safely by following evidence-based policies and procedures,
understand the proper procedures of mixing vaccines as well as proper vaccine storage and
where to locate the web links for additional educational materials in SRCs intranet. Employees
also need to be clear which vaccine supplies are for private pay clients and which are for public
pay clients and the need for them to be kept separate in order to satisfy the CDC and Washington
State Vaccine for Children guidelines (VFC, n.d.; Vaccines for Children Program, n.d.). In the
change stage, employees will have the knowledge, skills and confidence in the proper
administration of vaccine and understand how and where they are stored and be able to
document properly in the SRCs EMR, all the pertinent information required.
Our ultimate goal is to refreeze all of SRCs vaccinators to be all skilled, confident,
competent and to document 100% of all the pertinent information required in their EMR.
Hopefully with the implementation of this newly restructured immunization class, we can begin
to unfreeze the beliefs and attitudes of new employees as well as the current employees. With the
reinforcement of annual competencies for all vaccinators, the expectation will ultimately
change their view of the importance of their own immunization practices and having the
information in an easily retrievable format will help to refreeze the facility guidelines and
practices moving them towards the new norm.
In this project, we also proposed a PDSA cycle with the goal of reducing the number of
errors in documentation and administration of vaccines administered within the Skagit Regional

IMPROVING STAFF KNOWLEDGE AND SKILLS ON IMMUNIZATION

Clinic system by 90%. Since our time is limited, this project will need to be implemented after
we have completed our clinical experience this quarter. Hopefully, the facility and/or next cohort
will be able to gather data and evaluate the effectiveness of this proposed PDSA and make the
necessary changes to help reach our proposed goals (See Appendix B).
Force Field Analysis
The force field analysis is a valuable tool that we applied in our organization change
project. This model was developed by Kurt Lewin in the early 20th century for managing change
in the workplace. This is a tool that is widely used in the 21st century as one of the most
effective models for organizational change and business improvement (Change Management
Consultant, 2016) and assesses the organizations driving forces and restraining forces to aid the
process of changing an organizations current equilibrium and status quo. Our expectation is for
SRC to achieve an organizational culture of immunization competency by improving staff
education on vaccine administration and documentation.
For SRC to adopt the necessary changes in their organization, we first identified some of
the challenges the organization faces in the form of forces that may be restraining change. There
is inadequate knowledge by staff members about Vaccine for Children (VFC) that are being
offered for children from birth to 18 years by the state and this needs to be clarified through staff
education. As a driving force, the immunization class will help staff and new employees to be
educated on the VFC program. Another restraining force impeding the organization to adopt a
culture of immunization is incomplete documentation of vaccine administration. Per our mentor,
missing documentation of vaccine lot numbers was noted to be a problem. Due to the upcoming
adoption of EPIC software within the organization, the Information Technology (IT) department

IMPROVING STAFF KNOWLEDGE AND SKILLS ON IMMUNIZATION

is not able to make hard stop changes to the current EMR. Staff education and reinforcement on
the importance of precise documentation of vaccine administration will increase awareness and
compliance (See Appendix C).
Due to inadequate staff knowledge on CDC and WA. DOH immunization requirements
and their busy work schedule, SRC staff do not have adequate time to document all the pertinent
vaccine information in NextGen. This is a restraining force that needs to be addressed. In
alignment with the CDC and WA. DOH, educational materials and resources in the
immunization class will help clarify and educate staff about vaccine requirements and direct staff
to access resources more easily in their day-to-day work environment.
The organizations participation in AFIX is among the driving forces. AFIX is defined as:
Assessment of the immunization coverage of public and private providers, Feedback of
diagnostic information to improve service delivery, Incentives to motivate providers to change
immunization practices or recognition of improved or high performance, and eXchange. (CDC,
2015, p. 34) and is a program offered by the CDC. SRC participation in the AFIX program
increases the driving forces in adopting a culture of immunization in the organization by
increasing reimbursement based on the increases in documented completed immunizations
(CDC, 2015). This program is a positive force to encourage staff to properly enter the
appropriate vaccination dates and AFIX data. Improved documentation will lead to improved
reimbursement rates that will ultimately assist the organization in remaining fiscally responsible.
Recommendations

The revamping of the SRC Vaccine and Immunization class will propel the organization
toward positive change in the form of adopting a culture of immunization. This class will educate

IMPROVING STAFF KNOWLEDGE AND SKILLS ON IMMUNIZATION

SRC staff about the differences between state supplied vaccines and private pay vaccines. Staff
will be educated about the VFC program, how to locate VFC supplies and who are eligible for
the VFC program (VFC, n.d.; Vaccines for Children Program, n.d.). Through this education
class staff will become competent in appropriately identifying VFC supplies. Overall, this will
prepare SRC staff to understand CDC and WA. DOH guidelines regarding vaccine storage and
handling and administration and increase staff knowledge in locating resources for vaccines and
immunizations in their clinic.
The vaccine administration documentation is very important in order for SRC to stay in
compliance with CDC and WA. DOH guidelines. Our mentor, Kirty M., RN stated that proper
documentation allows for the information to cross over to the Washington Immunization
Information System (WAIIS) which will allow the WA. DOH the ability to assess more
accurately the immunization rates in our community. This will be reflected in improved
vaccination rates for all age groups that are of concern and are currently being monitored and
assessed through the Skagit Community Health Assessment Survey Annual Report (2015).
As recommended by the CDC, knowledgeable staff is the key to understanding and
preventing vaccine administration errors. As part of SRCs policy and procedures, the CDC
recommends staff training and education on vaccine storage and handling and proper
administration to be a part of new employee orientation and annual trainings for all staff
involved in vaccine administration. They also encourage staff to be informed whenever
recommendations are updated and when new vaccines are added (Weaver, 2015). To prevent
errors on administration of a vaccine without the proper diluent, the CDC recommends to keep
vaccines and diluents in original packaging with lids on to maintain temperature and protect from

IMPROVING STAFF KNOWLEDGE AND SKILLS ON IMMUNIZATION

light. Other recommendations include stacking each type of vaccine with the required diluent in
rows 2-3 inches apart and the use of labels with vaccine type, indications or color coding to
prevent errors.
An immunization champion can help overcome the barrier of staff resistance to change
and/or feelings of intimidation. Per our mentor, staff may feel intimidated or embarrassed to ask
for help on proper vaccine administration. Also regarding the differences between federal and
state immunization requirements due to the lack of staff not administering vaccine on a regular
basis. Evidence-based strategies recommend bringing resources and information to staff
regularly, tracking and reporting on progress towards goals, offering coaching to staff and
reinforcement for employees on how their role supports immunization and vaccination in the
organization (Oregon Health Authority, n.d). If adopted, these recommendations can help the
organization overcome restraining forces and smooth the transition of change.
Conclusion
Many studies show the effectiveness of immunization and the many numbers of lives
saved from preventable diseases in all ages, and yet one in every four children is not immunized,
leading to almost three million unnecessary deaths every year. As healthcare workers, it is our
obligation to champion for the lives of the people we serve and provide them with the highest
quality health care available. We can start that in the community we serve by understanding the
most effective ways to administer these immunizations against vaccine preventable diseases. As
employees of SRC, education and knowledge are the fundamental keys to success. Being open to
new changes is a start, and adopting recommended evidence-based practices on vaccine storage,

IMPROVING STAFF KNOWLEDGE AND SKILLS ON IMMUNIZATION

handling and administration, will lead to confident and competent staff to serve SRCs
community.

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References
ACIP | Home | Advisory committee on immunization practices | CDC. (n.d.). Retrieved
November 2016, from https://www.cdc.gov/vaccines/acip/
Cameron, N. (2009). Why do we immunize children? Professional Nursing Today, 13(3), 36
41.
Center for Disease Control and Prevention (2015). Immunization strategies for healthcare
practices and providers. Retrieved from
https://www.cdc.gov/vaccines/pubs/pinkbook/downloads/strat.pdfhttps://www.cdc.gov/vac
cines/pubs/pinkbook/downloads/strat.pdf

Change Management Consultant: Force field analysis free step-by-step guide to Kurt Lewin
Force Field. Retrieved November 7, 2016, from http://www.change-managementconsultant.com/force-field-analysis.html

Immunization & Child Profile Office, Washington State Department of Health. (n.d.).

Retrieved October 18, 2016, from

http://www.doh.wa.gov/ForPublicHealthandHealthcareProviders/PublicHealthSystem
ResourcesandServices/Immunization

Immunization Schedules | CDC. (n.d.). Retrieved October 30, 2016, from

https://www.cdc.gov/vaccines/schedules/
Lewins Change Management Model: Understanding the three stages of change (n.d.). Retrieved
October 31, 2016, from http://www.mindtools.com/pages/article/newPPM_94.htm
Oregon Health Authority (n.d). Evidence-based strategies for improving childhood immunization
rates: A guide for ccos. Retrieved from

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https://www.oregon.gov/oha/analytics/CCOData/Childhood%20Immunizations%20

Resource%20Guide.pdfhttps://www.oregon.gov/oha/analytics/CCOData/Childhood
Immunizations Resource Guide.pdf

Sare, M., and Ogilvie, L. (2010). Strategic planning for nurses: Change management in health
care. Burlington, MA: Jones and Bartlett learning. 171-194
State Vaccination Requirements | CDC. (n.d.). Retrieved October 19, 2016, from
http://www.cdc.gov/vaccines/imz-managers/laws/state-reqs.html
School and Child Care Immunization: Washington State Department of Health. (n.d.). Retrieved
October 13, 2016, from
http://www.doh.wa.gov/CommunityandEnvironment/Schools/Immunization
Vaccines for Children Program, Washington State Department of Health. (n.d.). Retrieved
November 30, 2016, from

http://www.doh.wa.gov/ForPublicHealthandHealthcareProviders/PublicHealthSystem
ResourcesandServices/Immunization/VaccinesforChildren

VFC | Home | Vaccines for Children Program | CDC. (n.d.). Retrieved November 29, 2016, from
http://www.cdc.gov/vaccines/programs/vfc/index.html
Weaver, D. L. (2015). Vaccine storage and handling and administration. CDC. Retrieved from
https://www2.cdc.gov/vaccines/ed/epvreg/Downloads/EPV4.pdf
WHO | 10 facts on immunization. (n.d.). Retrieved October 20, 2016, from
http://www.who.int/features/factfiles/immunization/en/

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Appendix A
Vaccine and Immunization Class: Education Logic Model

Statement of Need: Improving Staff Knowledge and Skills on Immunization

Resources/inputs

Activities

Outputs

Outcomes

Impact

In order to
accomplish our
set of activities,
we will need the
following:

In order to
address our
problem or
asset, we will
accomplish the
following
activities:

We expect that
once
accomplished
these activities
will produce the
following
evidence or
service delivery:

We expect that if
accomplished
these activities will
lead to the
following changes
in 1-3 then 4-6
years:

We expect that if
accomplished
these activities
will lead to the
following
changes in 7-10
years:

Skagit Regional
Clinic
Kirty Morse,
Vaccine
coordinator

Educate new
employees in
best practices of
giving
immunization

Well informed,
knowledgeable,
and confident
vaccinators

Initial injection
and vaccination
administration
program during
New Employee
Orientation

Annual
immunization
competency for
new and current
employees who
administer
injections and
vaccinations

New employees
will know where
to find the web
links for
additional
resources
necessary for
proper
immunization

Employees are
knowledgeable
with the supplied
web links and able
to navigate them
easily

Employees are
confident at
locating
immunization
procedures and
safety
information on
hospital intranet.

Educational
materials and web
links for
immunization
class

Have new
employees
access
computers to
navigate the
web links for
immunization
class/material

Skagit Regional
Clinic
Next-gen
computer charting
program

Teach new
employees how
to correctly
document in
next-gen

New employee
will document in
Next-gen
properly.

New employee
documentation in
Next-gen will
become a routine
skill and will not
miss documenting

100%
documentation
compliance

IMPROVING STAFF KNOWLEDGE AND SKILLS ON IMMUNIZATION

Available Vaccine New employees

tool kit
to practice
for new employee drawing up

diluents and

vaccine from
vials

vaccine
administration
accurately

New employees
will be confident
in properly
preparing
vaccines

Immunizations
will be given with
minimal risk of
complications

Organization
Employees
versus State
educated about
Supplied vaccines the differences

between the
organization
supplied versus
State supplied
vaccines

Employees will
know where
public pay and
private pay
patients vaccines
are located or
stored

Skilled,
knowledgeable,
well-trained
vaccinators

Confident and
knowledgeable
new employee
who is efficient
and caring with
giving
vaccination

Employees will
pull the right
vaccines for the
right eligible
patient

Rates of
childhood
immunizations in
our community
of interest will be
at or above the
national average
State supplied
childhood
vaccines will
remain separate
from privately
provided
vaccines

Preceptor for
new employees
at SRC

14

Patients will feel at

ease knowing that
vaccinators are
confident in giving
immunizations

Improved
immunization
rates in Skagit
County residents

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Appendix B

PROPOSED PDSA CYCLE

The aim of our project this quarter is to reduce the number of errors in documentation and
administration of vaccines administered within the Skagit Valley Regional Clinic system by
90%. This is a project that will need to be implemented after we have completed our clinical
experience this quarter. Our PDSA recommendations for the facility and/or future Western
Washington University cohorts are documented below.

Plan-

To revamp the New Employee Orientation Injections and Immunizations

class.
Do---- Reviewed class contents, reorganized into more logical sequences, removed

redundancies and made review and access easily available on Skagit Valley
Regional Clinic Intranet.
Study- Collect data after administering class contents to 4 rounds of new employees
on rate of documentation errors per 1000 patient encounters in Skagit
Valley Regional Clinics.
Act--- We recommend evaluation of results after 120 days of implementation to

determine effectiveness of changes to program on impacting errors in
documentation and administration of vaccinations at Skagit Valley Regional
Clinics.

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Appendix C

Force Field Analysis

Restraining Forces

Driving Forces

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Appendix D

Revamping Skagit Regional Clinic Vaccine and Immunization Class

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