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Policy Innovation Profile

Health System Makes Annual Influenza Immunization a Condition of Ongoing Employment, Leading to Near-Complete Vaccination of Workforce


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Snapshot

Summary

BJC HealthCare instituted a policy requiring all employees to get an annual influenza vaccination as a condition of ongoing employment. Each flu season, the health system reminds employees about the policy through various communication vehicles, and makes vaccines available free of charge at multiple, convenient locations and times. Exemptions can be granted for religious or medical reasons. Supervisors track their employees' vaccination status through a database, and those who do not comply are subject to corrective action. The policy has significantly increased vaccination rates, to the point that virtually the entire workforce receives a flu shot each year.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of influenza vaccination rates among health system employees.
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Developing Organizations

BJC Healthcare
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Use By Other Organizations

A few other health care organizations require employees to be vaccinated each year, including Virginia Mason Hospital.

Date First Implemented

2008
Fall

Problem Addressed

Although numerous organizations have long recommended that health care employees be vaccinated against influenza each year, vaccination rates among these workers remain suboptimal.1,2 Unvaccinated workers can contribute to institutional outbreaks of flu, which puts vulnerable patients at increased risk of infection.
  • Low vaccination rates for health care workers: The Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices and many other organizations recommend that all health care workers be immunized against the flu each year, due in part to their frequent contact with infected patients and their ability to spread the highly contagious virus to patients and coworkers.3,4 Though vaccination rates among health care workers have gradually improved over the last 5 to 10 years, with rates reaching 63.5 percent during the 2010 to 2011 influenza season,5 rates still remain suboptimal. In the decade before BJC HealthCare implemented its mandatory immunization policy (1997 to 2006), between 44 and 60 percent of employees did not get the vaccine each year. However, in locations where employers require vaccination, coverage rates are at around 98 percent.5
  • Leading to hospitalizations, deaths, and high costs: Across the country, influenza kills roughly 24,000 individuals each year.6 At the micro level, outbreaks on individual hospital units can be quite devastating and costly. For example, an influenza outbreak in which nearly a quarter of staff on an internal medicine ward became ill cost the facility over $34,000, including 14 person-days of sick leave, postponement of 8 scheduled hospital admissions, suspension of emergency admissions for 11 days, and payment of overtime to staff who replaced influenza-infected workers.1

What They Did

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Description of the Innovative Activity

BJC HealthCare instituted a policy requiring all employees to get an annual influenza vaccination as a condition of ongoing employment. Each flu season, the health system reminds employees about the policy through various communication vehicles, and makes vaccines available free of charge at multiple, convenient locations and times. Exemptions can be granted for religious or medical reasons. Supervisors track their employees' vaccination status through a database, and those who do not comply are subject to corrective action. Key program elements include the following:
  • Policy mandating annual vaccination: The policy makes annual influenza vaccination a condition of employment, regardless of job function. The policy covers all clinical and nonclinical BJC employees, as well as volunteers, students, and vendors who are providing services in patient care areas for extended periods of time (in other words, vendors refilling candy machines are not included in the policy). The policy also covers all hospital-employed physicians, including hospitalists, residents, and fellows; however, it does not cover the majority of attending physicians who are in private practice or are employees of the Washington University School of Medicine. Under the policy, covered individuals must receive a vaccination or be granted an exemption between October 15 and December 15 of each year, with new hires being vaccinated through March 31. The required vaccines may vary from year to year, depending on flu outbreaks and pandemics. For example, in the 2009 to 2010 season, the organization required that employees receive the seasonal influenza vaccine and the H1N1 vaccine.
    • Multiple communication vehicles: Employees receive reminders about the policy from their supervisors, who use standard education materials including fact sheets and talking points developed by the health system. Employees also see reminders on the organization's Intranet and in the organizational newspaper articles. Individual BJC facilities use additional communication methods, such as letters mailed to employees’ homes and town-hall meetings during the vaccination season led by infectious disease physicians and occupational health nurses who answer questions.
    • Free vaccines, administered at convenient times and locations: The system makes it as easy as possible for employees to be vaccinated, with vaccines offered free of charge at multiple locations within all facilities. BJC uses occupational health staff to administer the vaccine during set times and locations; per diem nurses to staff large immunization campaigns held in facility cafeterias at the start of each flu season; and unit-based registered nurses to serve as liaisons for the program, administering vaccines to colleagues.
    • Exemptions: Employees can request an exemption from the requirement for religious or medical reasons (as outlined below) and receive a response within 5 days. Employees granted an exemption are encouraged to use face masks when in patient care areas during the influenza season.
      • Religious exemptions: Employees must submit a letter to the Human Resources Department stating a religious-based opposition to vaccination. Employees must reapply for this exemption each year.
      • Medical exemptions: Employees must submit a standard medical exemption form completed by a licensed physician describing a medical contraindication to the vaccination. Accepted medical contraindications include hypersensitivity and/or allergy to eggs, prior hypersensitivity to the influenza vaccination, and a medical history of Guillain-Barre syndrome. Occupational health nurses review requests on a case-by-case basis. Any questionable requests are referred to a physician with expertise in vaccinations and the physician who wrote the letter may be contacted for further clarification. Exemptions may be granted on a temporary or permanent basis depending on the reason for the medical exemption.
    • Tracking vaccination status: The health system maintains a database to track employees’ vaccination status, with occupational health personnel (and, in some cases, department managers) updating it as employees are vaccinated. For vaccines administered at BJC, employees complete a carbon-copy consent form. The person administering the vaccine sends the top copy to the facility’s occupational health office for entry into the database and filing in the employee’s health record. The employee keeps the bottom copy as proof of vaccination. In some facilities, managers can update the status of an employee who receives a vaccine administered on the unit. Employees vaccinated at other locations must submit proof (e.g., a physician’s note or a receipt from a pharmacy) to the occupational health department, which enters the information into the database. Volunteer vaccination status is tracked through the volunteer offices, student vaccination status is tracked by the school, and vendor vaccination status is tracked through a commercially available health care vendor credentialing system.
    • Supervisor monitoring of status: Department supervisors can review a separate database linked to the occupational health database through the health system’s Intranet. Through this database, they can monitor the vaccination status of every member of their staff. In some facilities, occupational health generates weekly reports listing compliant (vaccinated or exempt) and noncompliant (not vaccinated, nonexempt) employees. Supervisors also receive periodic system-wide updates about progress toward the goal of full vaccination, with reminders to use the database to monitor their employees. Supervisors can talk with staff who have not yet complied during the current season (to find out why), provide information to them about the benefits and rationale for mandatory vaccinations, and discuss the consequences of continued noncompliance (see bullet below).
    • Meaningful consequences for noncompliance: Employees who are not vaccinated or exempted by December 15 are suspended without pay. Those who obtain a vaccination or exemption prior to January 14 can return to work, while those who do not may face termination. Noncompliant volunteers and students are not allowed to work or train in BJC facilities without meeting the requirements of the policy, and vendors are denied access to the facilities.

    Context of the Innovation

    BJC HealthCare is a large system in the Midwest with approximately 28,000 employees working in 11 acute care hospitals (ranging from 40 to 1,250 beds) and 3 extended care facilities. The organization also has daycare centers, employed physician groups, occupational medicine facilities, home care, and behavioral health services. The impetus for this program came from historically low vaccination rates among employees, which, as noted earlier, ranged from 40 to 60 percent a year between 1997 and 2006 (well below the organization's goal of 80 percent). These low rates persisted despite annual campaigns offering free vaccines made conveniently available at different sites and times, extensive publicity and education, and incentives for participation. BJC initially tried to boost rates by adding the workforce's immunization rate to the organization’s quality scorecard, and by asking workers who refused to be vaccinated to sign statements acknowledging the risks to themselves and patients. This effort brought vaccination rates up to 71 percent, a level still short of the goal. At this point, the organization’s Excellence in Patient Care Committee—which includes chief medical and nursing officers from across the organization—proposed making influenza vaccination a condition of employment.

    Did It Work?

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    Results

    The program has significantly increased vaccination rates, leading to the near-complete vaccination of the workforce.
    • Increase in vaccination rates: In the 2008 flu season (the first season after implementation of the policy), vaccination rates increased by 43.4 percent over rates during the 2006 flu season, and by 26.5 percent over the 2007 season. Since implementation of the policy, BJC HealthCare has been able to maintain vaccination rates above 97 percent each year.
    • Near-complete vaccination of workforce: Since the 2008 flu season, virtually the entire workforce has been vaccinated, a level that has been sustained since that time. In that year, 98.4 percent of the system's 25,980 active employees received a flu shot (vs. between 44 and 60 percent of employees in the 10-year period before the implementation of the policy, as previously noted). Another 411 employees received either religious or medical exemptions, bringing effective compliance to the policy to 99.96 percent of the workforce. Only eight employees were terminated for noncompliance.

    Evidence Rating (What is this?)

    Moderate: The evidence consists of pre- and post-implementation comparisons of influenza vaccination rates among health system employees.

    How They Did It

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    Planning and Development Process

    Selected steps included the following:
    • Writing draft policy: The Excellence in Patient Care Committee partnered with human resources to draft the written policy making annual influenza vaccinations a condition of ongoing employment.
    • Refining policy based on feedback: The legal department reviewed the draft policy, after which it was presented to the system chief executive officer and hospital presidents and to the human resources executive council to obtain their feedback and support. The policy was refined based on this feedback.
    • Developing communications plan: The program director of BJC occupational health services and a human resources representative developed a detailed plan to communicate and educate employees about the new policy. The plan outlined various communication strategies, including campaign content and messengers, target audiences, and timing.

    Resources Used and Skills Needed

    • Staffing: The program largely uses existing staff, including unit-based nurses and occupational health staff who administer vaccines. Each year, nurses paid on a per diem basis are hired to administer vaccines to employees as part of large campaigns held the first few weeks of each flu season.
    • Costs: Data on program costs are unavailable. The primary costs include the cost of the per diem nurses and the additional doses of vaccine administered as a result of the increase in vaccination rates. Since the policy is mandatory, the system no longer incurs the cost of employee incentives (financial prizes and small token gifts) offered during previous campaigns.
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    Funding Sources

    BJC Healthcare
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    Tools and Other Resources

    Recommendations regarding influenza vaccination are available at:
    • Fiore AE, Shay DK, Broder K, et al., Prevention and control of influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP), 2008. MMWR Recomm Rep 2008;57:1-60: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5707a1.htm
    • Centers for Disease Control and Prevention (CDC). Prevention and control of influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP), 2011. MMWR Morb Mortal Wkly Rep 2011;60:1128-1132: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6033a3.htm.

    Information regarding mandatory influenza vaccination policies including position statements and related articles is available at the Immunization Action Coalition's Honor Roll for Patient Safety Web site: http://www.immunize.org/honor-roll/.

    Adoption Considerations

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    Getting Started with This Innovation

    • Allow sufficient planning time: Development of this type of policy can take up to a year, due to the need to obtain senior management approval, design and communicate a new human resources policy, and set up mechanisms for convenient immunizations for staff.
    • Emphasize impact on safety: Mandatory policies should be justified by emphasizing the goal of improving the safety of patients and employees, their families, and the entire community. In this instance, the policy protects these stakeholders from influenza infection and its associated risks.
    • Involve key partners in development and implementation: Senior leaders and staff from various departments (including human resources, occupational health, infection control, and legal) should participate in the development and implementation of the policy.
    • Educate to counter misinformation: Employees may be misinformed about influenza vaccination. Educational efforts can serve to debunk myths about the risks of and contraindications to vaccination.
    • Thoroughly explain policy, including time frame and consequences: The policy should clearly state the time frame for compliance, when and how exemptions will be granted, and the consequences of noncompliance.

    Sustaining This Innovation

    • Ensure consistency from year to year: The message underlying the policy and the specifics (e.g., time frame, exemptions) should remain consistent over time so that employees know what to expect and what is expected of them.
    • Share compliance rates with employees: At the end of each season, communicate current compliance rates to employees. Employees who see the success of the policy will be more likely to continue to be vaccinated in future years.

    Use By Other Organizations

    A few other health care organizations require employees to be vaccinated each year, including Virginia Mason Hospital.

    More Information

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    Contact the Innovator

    Nancy Gemeinhart
    Program Director, Occupational Health Services
    BJC HealthCare
    Center for Clinical Excellence
    8300 Eager Road, Suite 400A
    Mail Stop: 92-92-241
    St. Louis, MO 63144
    314-856-3986
    E-mail: nxg1479@bjc.org

    Innovator Disclosures

    Ms. Gemeinhart reported no financial interests or business/professional affiliations relevant to the work described in this profile.

    References/Related Articles

    Babcock HM, Gemeinhart N, Jones M, et al. Mandatory influenza vaccination of health care workers: translating policy to practice. Clin Infect Dis. 2010 Feb 15;50(4):459-64. [PubMed]

    Footnotes

    1 National Foundation for Infectious Diseases. Influenza Immunization Among Health Care Workers. Call to Action: Improving Dismal Influenza Vaccination Rates Among Health Care Workers Requires Comprehensive Approach, Institutional Commitment. Available at: http://www.nfid.org/pdf/publications/calltoaction.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.).
    2 Greene L, Cain T, Dolan S, et al. APIC Position Paper: Influenza Vaccination Should Be a Condition of Employment for Healthcare Personnel, Unless Medically Contraindicated. Washington DC: Oct. 1, 2008. Available at: http://www.apic.org/Resource_/TinyMceFileManager/Advocacy-PDFs
    /APIC_Influenza_Immunization_of_HCP_12711.PDF
    .
    3 Centers for Disease Control and Prevention (CDC). Prevention and control of influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP), 2011. MMWR Morb Mortal Wkly Rep. 2011;60:1128-1132. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6033a3.htm. [PubMed]
    4 Immunization of health-care workers: recommendations of the Advisory Committee on Immunization Practices (ACIP) and the Hospital Infection Control Practices Advisory Committee (HICPAC). MMWR Recomm Rep. 1997;46(RR-18):1-42. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/00050577.htm. [PubMed]
    5 Centers for Disease Control and Prevention (CDC). Influenza Vaccination Information for Health Care Workers. Available at: http://www.cdc.gov/flu/healthcareworkers.htm.
    6 Centers for Disease Control and Prevention (CDC). Estimates of deaths associated with seasonal influenza—United States, 1976-2007. MMWR Morb Mortal Wkly Rep. 2010;59(33);1057-1062. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5933a1.htm. [PubMed]
    Comment on this Innovation

    Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

    Original publication: September 26, 2012.
    Original publication indicates the date the profile was first posted to the Innovations Exchange.

    Last updated: October 09, 2013.
    Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

    Date verified by innovator: September 30, 2013.
    Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.

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