The fourth pillar of the 4PPTP is Motivation of the clinical team. Making changes to established workflows and to office systems is not easy. A common objection to any quality improvement program is some variation on the lack of time and resources. From this perspective of resource scarcity, the very thought of conducting a deep, multi-system, multi-component intervention is almost farcical. Yet if change in outcomes is expected, then some change must occur. Faced with this reality many clinicians fall to the default intervention; education. The assumption is natural. One assumes that if he or she knows more, or can teach patients more, then positive results will follow. Unfortunately, in the domain of immunization, education is necessary, but not sufficient, to achieve measurable changes in vaccination rates. The kinds of changes that are required stress leverage points at every level of the healthcare organization and beyond. Immunization interventions are complex, multi-faceted, and involve many stakeholders. All
complex intervention during his/her career; one that never got off the ground or if it did take flight, crashed into a wall of obstinate habits, stoic willfulness, or entrenched bureaucracy. Motivation is the dynamic that pushes individuals to move past these barriers.
An observant reader may have already noted that the majority of strategies to overcome immunization barriers are really designed, though automation and habituation, to overcome our shortcomings as human beings. It is laughably ironic that engineering around human fallibility is, itself, subject to yet another level of human interference. Even the most carefully orchestrated and flawlessly planned quality improvement program can be hamstrung at the human/plan interface. But there is more to this story than fatalistic pessimism. How does one achieve change if it is so hard to do? How is it that some of the most haphazard and impromptu programs can succeed? Why do some practices consistently immunize the majority of their patients under the same organizational constraints? The answer, of course, is motivation. (72, 73)
The Community Guide recommends assessing vaccine providers’ performance and offering feedback.(37) Though there is considerable evidence that feedback on past vaccination performance tends to increase future performance, the active mechanisms are relatively unexplored. The exact nature of an “audit” and of “feedback” is highly variable. For example, in the literature reviewed by the Community Preventive Task Force, an audit may be conducted as infrequently as every five years or as often as weekly. Similarly, feedback may be a list of unvaccinated patients, provider education, or even financial incentives tied to vaccination rates. Also, few studies examine audit and feedback in isolation. Many reports include co-occurring interventions or are confounded by secular trends. More research will be necessary to isolate and test different methodologies and causal pathways.(74)
Organizational motivation is a potential mediator in the effectiveness of audit and feedback strategies. Immunization interventions are complex and often involve individuals and business units who do not have close working relationships. Special care should be taken to engage all stakeholders in appropriate planning and preparation to secure institutional buy-in of the program. Failure to do so, may result in insufficient institutional motivation or even overt sabotage that will derail the project. (75) Applying the principles of implementation science can help to guard against these risks. The planning, deployment, and implementation of the program should be considered as carefully as each of the program activities.
Immunization programs are dependent on team participation. If clinicians improve individual performance with audits and feedback, it stands to reason that teams will improve group performance with the same. The 4PPTP recommends the nomination of an immunization champion (IC) to serve as a team motivator.(48) This individual should be respected by the staff as a leader and be able to guide staff through system changes. (49) The IC should also have strong interpersonal skills and enjoy frequent communication. The ideal IC finds win-win solutions to conflicts and demonstrates tenacity in overcoming roadblocks. Finally, the IC should be committed to the quality improvement goal and be nominated as the IC through purposeful consideration and not simply by default.
Section 2.4.1 lists evidence-based strategies that the IC can employ to provide feedback to the team. In generating motivation, the quality of the audit is less important than the quality of the feedback. Obviously, audit results must be truthful, but absolute precision is unnecessary. ICs should use the data at hand to develop the best possible description of the practice’s baseline vaccination rates, generate reasonable but challenging targets and then start implementing strategies to try to improve rates. Someday all practices using an EMR will be able to summon an
accurate population-based report of real-time vaccination rates. Until that day arrives, using the readily available reports and measuring success as a change over baseline is sufficient. If no reports are available, simply tracking the number of doses administered per period, or manually auditing some small sample of charts is preferable to implementing a quality improvement program with no measures of effectiveness.
Practice managers and organizational leadership can also provide a special kind of motivation. Operational policies like standing orders can be used to describe required job performance standards. By extension, employees can be compelled to fulfill these standards as a condition of employment. Though tempting, the formalization of best practices into job requirements may lead to more employee dissatisfaction than productivity.(76)
2.4.1 Pillar 4 - Motivation Strategies
• Create a chart to track progress. Set an improvement goal and regularly track progress (e.g., daily or weekly). Post the graph of progress in a prominent location and update it regularly.
• Provide ongoing feedback to staff on vaccination progress at staff meetings or through other forms of communication.
• Create a competitive challenge for the most vaccinations given among staff. • Provide rewards for successful results to create a fun-spirited environment.
2.5 The Evolution of the 4 Pillars™ Practice Transformation Program from Clinical Trials