A presentation provided to the British Columbia Immunization Committee summarizing the application of quality improvement methods to immunization services.

1. Improving Immunization Services
and Coverage at VIHA
April 25, 2017
BCIC
Courtenay, BC

2. Topics for Discussion
• Current state
• Examples of application of the Model for
Improvement to Immunization Practice
– HU specific initiatives, what has been learned
– Same day appointments
• Evolution of School Based Immunization

3. 2 Yr Old Immunization Rates
2007 – 2015
*source BCCDC report

4. 7 Yr Old Immunization Rates
(source: Panorama, Nov 1, 2016)

5. Operational Activities Supporting
Access to Immunization
• 2 mo to 2 yr old recall and reminder (expected
to be Island wide)
– ‘Audit’ schedule
– Post card reminders
• Routine appointment reminders (Island wide)
• School entry reminder, clinics, recall (unknown
scale and consistency)
• SBIC catch up in Gr. 6 and 9 (Duncan,
Parksville, Port Alberni, CV, CR, Mt. W.)

7. Immunization QI Projects
• Reduce time to appointment (target is 14 days)
– Group Imms Appts 2015 (SI) No benefit
– Same Day Appts 2016 (SI) Benefit
– Balance Appt. Demand and Availability 2014-15 (Nanaimo) Benefit
– Outreach Clinic (Nanaimo) Unclear benefit
– Monitor days to 3rd Next Appt 2015 (Island wide) Unclear benefit
• Social Media/Facebook Page (Nanaimo) Unclear benefit
• Increase K Coverage
– Kindergarten SBIC using Personalized Consents 2016 (SI) Benefit
• Nanaimo 18 mo Improvement Project
– Institute recall (audit) procedures 2016 Benefit
– E-mail reminders Unclear benefit

8. Eliminated
Drop In Clinic

9. Impact of Dedicated Recall Alone
56%
58%
56%
68%
64%
59%
74%
70%
76%
71%
75%
79% 79%
80%
68%
72%
70%
78%
82%
73%
82%
79%
89%
81%
83% 83%
87%
82%
50%
55%
60%
65%
70%
75%
80%
85%
90%
95%
2010 2011 2012 2013 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14
Up to date at 2 years
Minus 18 mth booster
Lead audit
PHN assigned
dedicated time
Nanaimo 2 year Immunization Rates
Birth Cohort

10. 2 Yr Old Up to Date for Age Rate Changes by HSDA
between
2014 to Nov 2016
What do the increases get attributed to?
• Measles outbreaks in 2015 anecdotally reported to result in increased demands
• Most QI projects have taken place in either 2015 and/or 2016
• QI project have focused on South and Central, nothing specific in North
68%
74%
76%
58%
64%
68%69% 70%
75%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
2014 2015 2016
South
Central
North
Linear (South)
Linear (Central)
Linear (North)

11. Questions/Discussion

12. Same Day Appointments
at Saanich Health Unit
South Island Pilot and Expansion 2015-2016
December 8, 2016
T. Niedjalski & C. Haselden

13. Addressing Appointment Wait Times
• During 2015, immunization appointment wait
times were 4-6+ weeks out depending on the
Health Unit
• The acceptable wait time rate was considered
to be 2 weeks.

14. Reasons for Long
Appointment Access Times
• School Based Immunization Clinics (SBIC) in
the fall impact resource availability for CHCs
and created access delays that could not be
managed
• Changes in public health priorities (e.g.
increase emphasis on school health)
• Following the collective agreement

15. Cancellations and No Shows
• High number and frequent cancellations, or
‘no shows’
• Clients would not show up for appointments,
despite phone call reminder
• Parents had indicated that sometimes
“things just did not work out that day”

16. Other Options Tried
• Increasing # of CHCs – not always possible due
to other duties and efforts to ensure
distribution and variety of type of work
• Drop in clinics – not a good option at sites
tried
• Group appointments – tested but results did
not suggest improvement

17. A Potential Solution?
• Variation of Just-in-Time/Pull approach
• Developed as part of the Toyota Production System
• Originally referred to the production of goods to meet
customer demand exactly
• It meets needs in time, quality, and quantity, whether
the ‘customer’ or another process is the final
‘purchaser’ of the product further along the
production line.
• JIT examined as a way to improve:
• Responsiveness to public interests
• Time to access CHC appointments
• Improve use of PHNs

19. Eliminating Waste
According to JIT there are 7 types of waste:
• Waste from overproduction
• Waste of waiting time
• Transportation waste
• Processing waste
• Inventory waste
• Waste of motion
• Waste from product defects

20. Waste at the Health Unit
• Scheduled PHN time
• Admin time
• Appointments (up to 50% no show rate)
• Missed opportunities for other families
(waiting for an appointment)

21. Application of JIT/Pull for CHCs
• Original test was est. at Esquimalt Health Unit
• Supply remains dependent on est. capacity
each day
• Capacity for same day afternoon or evening
appointments is determined daily
• Parents who call the Health Unit in the
morning are offered same day appointment if
fits imms schedule

22. Spread within South Island
• Esquimalt Health Unit
• Saanich Health Unit
• Peninsula Health Unit
• Victoria Health Unit

23. No Shows
Booked vs Same Day appointment
• Number of No Show’s for booked
appointments from Jul 17th to Nov 25th, 2016
– VHU = 75
• Number of No Shows for Same Day
Appointments for same period
– 2 (this was the same person 2 Fridays in a row)

24. Success Story
• Parents have indicated that the same day
clinic works because on a particular day all the
pieces fall into place.
• Same day clinics have resulted in fewer missed
appointments and better utilization of PHN
time

25. Can the innovation be spread?
• Attempted at Comox Valley Community Health
Centre
• Significantly smaller population served
• Low/no parent interest
• Time to access an appointment significantly
less than in SI

26. Questions/Discussion

27. Evolution of School Based
Immunization Clinics (SBICs) at VIHA
• Pre-2013 Mass Imms Module in iPHIS
• 2009-10 development of SBIC Took kit (BCIC funded)
– Response to change cultural orientation to improve quality
and safety
• 2014 (re) introduction of mass imms in Panorama
• 2015 introduction of personalized consents at three schools in
Comox Valley in 2015
• 2016 expansion of personalized consents to all communities
except SI and Nanaimo
• 2017 introduction of STIX and expansion of personalized
consents to entire region (approximatly 12,000 students)

28. Planning Considerations for Expansion
for 2017-18
• Improvements to tool/workflow/reports
(feedback integrated/provided in 2015-16, in
progress for 2016-17)
• Impact on schedule of:
– Receiving and reconciling student records from MoE
systems
– Personalized consent prep, distribution, and return
– Impact on SBIC schedule compared to ‘old best way’
• Distribution of generic consents required school population
numbers only
• Consents could be distributed and returned before end of
September
• Addition of HPV for boys

29. Planning Considerations for Expansion
in 2017-18
• South Island HSDA
– Approx 6,000 students are immunized
– Impact of SBIC resource requirements on overall PH
capacity (CHC, influenza program, fridge capacity)
– Consideration to immunize based on history for grade 9
students only
• Nanaimo
– Analysis needs to be completed and recommendations
derived.
• BCCDC
– Vaccine supply
• PCST
– Ongoing engagement with VIHA to receive feedback from
2016-17 cycle to make continues improvements to tools

30. Questions/Discussion
Brett Hodson
brett.hodson@viha.ca
250-331-8558
@hodson4qph