Quality improvement project assignment: Immunization in Manukau

Question

Task: You are the practice manager of a general practice in Counties Manukau DHB. You would like to improve immunisation coverage of children aged 5 years in the practice. Assume that the immunisation coverage of children aged 5 years in the practice (total and for sub-groups) is the same as for Counties Manukau DHB overall (from Assignment 1). You use The Community Guided (https://www.thecommunityguide.org/topic/vaccination) to identify an evidence-based intervention to increase increasing immunisation coverage of this age group. You organise a practice meeting and all staff agree that the most suitable intervention to try to implement in the practice is Provider Assessment and Feedback@ (https://www.thecommunityguide.org/findings/vaccination-programs-provider-assessment-and-feedback) .

Complete all of the following tasks:

1. Specify the key stakeholders for your project.

2. Specify who you would include in your project team.

3. Describe an aim statement that could be used for your project.

4. Outline how you might determine whether or not there is an improvement in immunisation coverage of children aged 5 years in your practice as a result of the project.

5. Describe how you might initiate implementation of the intervention (i.e. provider assessment and feedback) as part of a PDSA cycle.

6. Describe how your project could be focused towards a sub-group experiencing inequities in immunisation coverage.

7. Assuming that the intervention (i.e. provider assessment and feedback) is implemented fully and sucCessfully within the first practice, how might you sustain and spread this successful initiative to other practices?

Answer

Introduction
The present quality improvement project assignment examines the readings of Borgiel (1) that immunization relates to the procedure in which an individual is provided with the ability to become resistant to an infectious disease through the administration of the vaccine. The present study is based on the project to improve the immunization coverage among the 5 years old children within the counties of Manukau DHB. The present study developed within this quality improvement project assignment has identified that key stakeholder, as well as team members associated with the improvement of the immunization and developed the aim statement. The approaches to determine the improvement of immunization coverage has been highlighted through the segments of quality improvement project assignment.

1. Specification of the key stakeholders
In any project management, it is essential to identify the key stakeholders so that their interest and needs relating to the project can be identified and met effectively. The key stakeholders of the quality improvement project of the immunization in the counties of Manukau DHB are discussed in the following section of quality improvement project assignment:

• The children ageing 5 years
• Parents and family members of the children
• Healthcare practitioners and support service workers
• The Ministry of health
• Government
• Community

2. Project team members
In order to ensure the success of the quality improvement projects, it is important to involve knowledgeable professionals in the project team. The project team of the present quality improvement project would incorporate the members mentioned below within this quality improvement project assignment:

• Clinical leaders
• Senior leaders
• Immunization staff
• Nurses
• Physicians
• Suppliers of vaccine
• Representatives of government agencies

3. Aim statement
From the analysis of the data regarding immunization coverage of children aged 5 years in Counties Manukau DHB, it has been identified in the quality improvement project assignment that the status of immunization is lacking in specific ethnic groups and different groups. However, it is very important to achieve 95% immunization coverage nationality in Australia as a lesser immunization coverage can result in the outbreak of infectious disease. The National immunization coverage in Australia was identified to be 88.0% the highest immunization coverage was recorded in Wairarapa which is 32.1%. In Counties Manukau, the immunisation coverage was 89.6%. So, the present quality improvement project aims to enhance the immunization coverage among the children ageing 5 years in Counties Manukau DHB to 95%. The aim of this project is to identify the approaches that can be used to determine if improvement of the immunization coverage. Moreover, the evaluation of the improvement project is also aimed so that the extent to which the immunization coverage is increased with the implementation of this project can be identified in the quality improvement project assignment. The project also aims at spreading and sustaining the quality improvement initiative to other practices. Increasing the community demand is another major aim for this quality improvement project.

4. Approach to determine improvement
According to Harder (2), it is noted in this quality improvement project assignment that for the quality improvement project in relation to immunization coverage enhancement, it is very important to ensure the status of immunization coverage is regularly monitored. A monitor work plan can be used for follow-up activity implementation. In order to successfully monitor the immunization coverage in the present case data relating to population and immunization coverage should be gathered and compiled. After that, the existing problems should be identified and major causes behind the problems must be recognized to develop solutions. As opined by Adamu (3) Prioritization of tasks must be done to increase the progress of the quality improvement project.

Figure.1: Monitoring work plan (Source: Costello, 2019) [4]

In the opinion of Tan (5) to make the immunization coverage effective to prevent infectious disease outbreak, there are two ways that can be used to measure the efficiency of the immunization; measurement of the group-out rate and the measurement of the immunization coverage by each vaccine type. Dropout relates to the contrast between the children receiving immunization and those children who do not receive an immunization. In the present scenario of quality improvement project assignment, different tools can be used to measure the immunization coverage efficiency and improvement during the implementation and after the implementation of the project. A major tool to identify the improvement is a chart to monitor drop-out children ageing 5 years. Another tool that would be used to identify any improvement is a tracking system that would include immunization register and child immunization card (6). The household survey can be another important tool to track the improvements in the immunization coverage. For the present scenario of quality improvement project assignment, a tally sheet including a questionnaire for the convenient household survey would be used to recognize the possible improvements in immunization coverage.

5. Initiation of implementation of intervention as part of a PDSA cycle Provider assessment and feedback interventions are two aspects of evaluating the performance of the immunization providers for one or multiple vaccines. It has been identified in the quality improvement project assignmentthat provider assessment and feedback programs can be utilized individually as well as in the combination of additional interventions for increasing the rates of vaccination among people having different ages belonging to different populations and community settings (7). Herein quality improvement project assignment, it has been identified that implementation of intervention with provider assessment and feedback programs are highly effective in assessing the extent of delivery of one or multiple vaccinations to clients. Moreover, these interventions can also present immunization providers with feedback relating to their performance. The feedback involved in these interventions can also include other elements like benchmarking and incentives.

PDSA cycle
Plan
The immunization data of Counties Manakau District Health Board Children has depicted that the status of the immunization coverage is not very effective to prevent the outbreak of the infectious diseases that have been eradicated from Australia. The data portrays that children belonging to Asian ethnicity possess the highest immunization. On the other hand, in some other ethnicities like Pacific ethnicities, the immunization coverage is 88.8%. Apart from that the data also represented that the immunization coverage among the higher deprivation levels is very low. Therefore, the present quality improvement interventions will change the percentage of immunization coverage among the ethnicities that are identified to have low immunization coverage. Therefore, the quality improvement project and the intervention will change the status of immunization in Australia. The process that would be implemented to assess the improvement is Provider assessment and feedback interventions. When the percentage of the immunization coverage would enhance by 3-5% for the different ethnicities and deprivation levels, it can be assumed in regards to the case scenario of quality improvement project assignment that the status has been improved. The plan should also include actions that combine interventions at the community level.

Do
According to Jiang (8) the second stage of the PSDA cycle includes the initiation of the changes. Therefore, in the present scenario of quality improvement project assignment, the implementation of the intervention can be initiated in the second stage of the PSDA cycle. Assessment of the immunization provider’s performance would be started in this phase. Moreover, the phase would also involve activities like feedback collection from households regarding the extent to which children ageing 5 years are immunized by the service providers. During the implementation, it should be ensured that systems and programs are implemented that can encourage people to vaccinate their children ageing years to enhance the overall immunization coverage.

Study
There are some potential barriers outlined in this section of quality improvement project assignmentfor using the assessment and feedback for the immunization coverage improvement. These include administrative burden on the system and providers, inadequate information infrastructure, and complex immunization schedule. During the implementation of the quality improvement project, responsibility is needed to be taken for reviewing the metrics and progress of the project towards the goal in small increments. On the basis of the feedback and assessment results, in this stage determination of the required changes have to be done so that the identified problems can be mitigated that the overall improvement of the immunization coverage can be achieved.

Act
In the opinion of Malone (9), implementation of changes and modifications can be done in the last stage of the PDSA cycle. In the resent scenario, the continuous monitoring of quality improvement through intervention would generate some data based on which taking approaches are essential to make improvement in the initial plans. On the basis of the feedback received from the service users and the assessment of the immunization providers mentioned in the quality improvement project assignment, decision making is necessary to modify the implementation plan. Moreover, the data can also help in identifying the next step of improving the intervention.

6. Focus towards sub-group experiencing inequities
The immunization coverage data included different subgroups. On the basis of the ethnicities, the different subgroups identified are New Zealand population, the Maori population, the Pacific population, the Asian population and others. The other population within DHB area included Africans, Europeans, Latin Americans/Hispanics, and Middle Eastern. On the basis of area, the West coast has shown the lowest immunization coverage that is with 78.3% coverage. Therefore, through this quality improvement project, the major concentration must be provided on the immunization of children in the West Coast. The data on the immunization coverage among the different subgroups have helped in identifying that Maori subgroup had the lowest immunization coverage. Therefore, it is likely that the Maori population is experiencing greater inequalities and discrimination in relation to immunization. So, during the implementation of the quality improvement project, it is important to focus greatly on the evaluation of the improvement of immunization coverage continuously on the Maori population as compared to the other subgroups (10).

Apart from that, it has been also identified in the quality improvement project assignment that the other subgroups also have a low level of immunization coverage that is 82.0%. Therefore, similar attention would be also provided to other populations including the Africans, Europeans, Latin Americans/Hispanics, and Middle Eastern. Deprivation level of the population also plays a critical role in the growing inequality in immunization. Children at the deprivation level of 7-8 had immunization coverage of 89.3% and the children at the deprivation level of 9-10 had immunization coverage of 89.0%. Therefore, it is important to focus heavily on these two sub-groups while enhancing the overall immunization coverage nationally. From the data included in the excel sheet, Maori population and other ethnicities must be prioritised over the other subgroups.

7. Approach to sustaining and spreading the initiative to other practices
In relation to the overall impact of the intervention in improving the immunization coverage, it can be assumed that the intervention was successful in identifying the underlying issues through feedback and provider assessment. In this situation of quality improvement project assignment, it is important to spread awareness regarding the effectiveness of the providers’ assessment and feedback program interventions across different practice to enhance the immunization coverage at the national level. To sustain and spread the initiative of intervention in improving immunization coverage is essential to combine the interventions at the community level. For example, community-wide education can be combined with client incentives for promoting the initiative regarding vaccinations in the targeted population. By raising awareness among the service providers of immunization regarding the ways in which people can be encouraged to get vaccinated can be also regarded as an approach to spread the initiative at the community level. According to Manyazewal (11) educational interventions can also help in spreading initiatives to other practices.

It has been identified that structured feedback of information is able to develop change within the behaviour of the physicians. Therefore, it is likely that by sharing information to the physician regarding the effectiveness of the intervention used in the current quality improvement project. So, to sustain and spread this successful initiative to other practices the project management team members would be responsible for participating in effective communication with the other practitioners so that they can develop knowledge regarding the effectiveness of the intervention used in this particular project (12).

Conclusion
From the above study on quality improvement project assignment, it can be concluded that immunization quality improvement project is highly dependent on the effectiveness of the team members and the extent of fulfilment of the stakeholder’s needs. The present quality improvement project assignmenthas highlighted the use of providers’ assessment and feedback program as an intervention for monitoring the immunization coverage quality improvement project. Moreover, the ways in which the awareness regarding the intervention can be spread across the other practices have also been highlighted and explained within this quality improvement project assignment.

References
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(10) Bernstein, H.H., Monty, M., Yang, P. and Cohen, A., 2017. Increasing Tdap coverage among postpartum women: A quality improvement intervention. Pediatrics, 139(3), p.e20160607.

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Improving immunization capacity in Ethiopia through continuous quality improvement interventions: a prospective quasi-experimental study. Infectious diseases of poverty. 2018 Dec 1;7(1):119.

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