By Kelly M. Pyrek
A strengthened standard from the Joint Commission is adding additional weight to the importance of healthcare worker vaccination against influenza. As of July 1, 2012, the Joint Commission requires that all accredited healthcare organizations establish an annual influenza vaccination program for staff members and licensed independent practitioners. The standard should be very familiar to many infection preventionists, as six years ago the Joint Commission required that hospitals and long-term care facilities seeking accreditation establish an influenza vaccination program which includes educating about and providing influenza vaccination to healthcare professionals.
"The Joint Commission has had the standards IC.02.04.01 in place for hospitals for many years, going back to 2006," says Kelly L. Podgorny, DNP, MS, CPHQ, RN, project director in the Standards and Survey Methods Department, Division of Healthcare Quality Evaluation, at the Joint Commission. "When the Joint Commission conducted the field review for the revised standard, the majority of healthcare organizations that responded actually had a process in place prior to this new strengthening of the standard."
Three of the elements of performance will be phased in by July 1, 2013 for certain types of healthcare organizations such as ambulatory care, behavioral health care, home care, laboratory services, and office-based surgery programs, and for the Medicare/Medicaid certification-based long-term care program option. The Joint Commission explains that this phased implementation provides additional time for organizations to determine their influenza vaccination goals for licensed independent practitioners and staff, to begin measuring an influenza vaccination rate, and to make improvements to that influenza vaccination rate. This phased approach is not applicable to the critical access hospital or hospital programs or the traditional long-term care accreditation program option.
In addition to establishing a vaccination program, the IC.02.04.01 standard will require accredited healthcare organizations to set incremental goals for meeting a 90 percent coverage rate by 2020. Accredited organizations also will be required to measure and improve vaccination rates for staff.
Although vaccination is key to preventing influenza-related illness and mortality, the U.S. Department of Health and Human Resources (HHS) reports that vaccination rates for healthcare professionals remains below 60 percent. In 2010, HHS issued the Action Plan to Prevent Healthcare-Associated Infections: Influenza Vaccination of Healthcare Personnel which states: “Influenza transmission to patients by health care personnel (HCP) is well documented. HCP can acquire and transmit influenza from patients or transmit influenza to patients and other staff. Vaccination remains the single most effective preventive measure available against influenza and can prevent many illnesses, deaths and losses in productivity. Despite the documented benefits of HCP influenza vaccination on patient outcomes, HCP absenteeism, and on reducing influenza infection among staff, vaccination coverage among HCP has remained well below the national 2010 health objective of 60 percent.”
“Increasing flu vaccination rates for healthcare workers is important not only to help protect themselves, but also to reduce the risk of flu infection for patients or individuals served,” says Podgorny.
Dialogue about the importance of vaccination was proliferating not only within the Joint Commission, but within a number of professional and governmental organizations that were recommending influenza vaccination for all healthcare professionals, including the Centers for Disease Control and Prevention (CDC), the Association for Professionals in Infection Control and Epidemiology (APIC), and the Society for Healthcare Epidemiology of America (SHEA).
As a result, in 2010 the Joint Commission implemented its standard development process. It determined that standard IC.02.04.01 needed to be strengthened, based on the scientific literature and current national focus on influenza vaccination, and that the standard needed to be extended to all accreditation programs. Previously, the standard was applicable to the critical access hospital, hospital and long-term care accreditation programs only. In September 2011, the Joint Commission's board of commissioners approved revised standard IC.02.04.01 for all accreditation programs.
"The Joint Commission has a very robust process for developing standards," Podgorny says. "And we also provided a significant amount of free education to the healthcare organizations regarding standard IC.02.04.01."
One key step in the process was making the draft standard available for field comment on the Joint Commission’s website in the spring of 2011. According to an R3 (2012) report from the Joint Commission, the field review indicated that influenza vaccination for staff and licensed independent practitioners is an important issue for all of the accreditation programs. There were more than 2,000 combined responses to the field review and a substantial amount of qualitative responses. Themes that emerged in the qualitative data were similar across accreditation programs, such as the need for additional financial resources for implementation and a viewpoint that the revised standard infringes on an individual’s right to choose. The results of the field review indicated the following:
• The majority of respondents for all programs except home care indicated that their organizations have offered influenza vaccination to staff and licensed independent practitioners for five years or more, whereas only 43 percent of home-care providers reported that length of experience with vaccinations.
• Survey respondents had mixed responses as to whether or not the benefit of complying with the proposed revisions to the influenza vaccination standard would outweigh the resources required of their organization.
• Several organizations responded to the field review with formal letters detailing their responses including: American College of Emergency Physicians (ACEP); the American Nurses Association (ANA); APIC; the Infectious Diseases Society of America (IDSA); Hospital Corporation of America (HCA); and Trust for America’s Health. All of these organizations supported the Joint Commission’s overall goal to strengthen standard IC.02.04.01; however, APIC and IDSA encouraged the Joint Commission to consider strengthening the proposed standard with additional requirements, including mandating the influenza vaccination.
The strengthened standards stop short of asking accredited organizations to mandate influenza vaccination for staff as a condition of accreditation.
"The Joint Commission does not mandate the influenza vaccination, and we discussed this in a Perspectives article that was published several months ago," says Podgorny. "The Joint Commission considered strengthening the standard because influenza vaccination for healthcare personnel is a national agenda, with the majority of the professional organizations such as APIC and IDSA recommending influenza vaccination to protect staff and patients and families. Because the Joint Commission is very focused on patient safety, that was one of the major driving forces of strengthening the standard."
"This is a patient safety issue," Podgorny emphasizes. "Patients and visitors should not be acquiring influenza in healthcare institutions. The Joint Commission understands that there needs to be an infrastructure when there is a structured program and that takes resources, but again, it is a safety issue."
Podgorny recommends that infection preventionists and occupational health professionals dig deeper to uncover the obstacles to influenza vaccination uptake by healthcare workers. "There are a lot of misconceptions about the influenza vaccination among healthcare professionals. That became very clear when we were analyzing the data from the field review. Because healthcare workers are choosing not to get the influenza vaccination because of those misconceptions, the Joint Commission developed a 'myths and realities' document available free on our website for healthcare organizations to use to address these misconceptions. What is important for healthcare organizations to do is to understand the reasons why staff are choosing to not take the influenza vaccination, determine if it is because they are making a decision under a misconception, and then provide more education to help clarify and rectify those misconceptions. While the Joint Commission does not mandate the influenza vaccination but we see it as an extremely important patient-safety activity."
The elements of performance for Standard IC.02.04.01 are as follows:
1. The organization establishes an annual influenza vaccination program that is offered to licensed independent practitioners and staff.
2. The organization educates licensed independent practitioners and staff about, at a minimum, the influenza vaccine; non-vaccine control and prevention measures; and the diagnosis, transmission and impact of influenza. (See HR.01.04.01, EP 4)
3. The organization provides influenza vaccination at sites and times accessible to licensed independent practitioners and staff.
4. The organization includes in its infection control plan the goal of improving influenza vaccination rates. (See Standard IC.01.04.01)
5. The organization sets incremental influenza vaccination goals, consistent with achieving the 90 percent rate established in the national influenza initiatives for 2020.
6. The organization has a written description of the methodology used to determine influenza vaccination rates. (See also IC.02.04.01, EP 1) The Joint Commission recommends that organizations use the CDC- and the NQF-proposed performance measure to calculate influenza vaccination rates for staff and licensed independent practitioners. The CDC/NQF measure, however, does not include all contracted staff; therefore the Joint Commission recommends that organizations also track influenza vaccination rates for all individuals providing care, treatment, and services through a contract, since contracted individuals also transmit influenza.
7. The organization evaluates the reasons given by staff and licensed independent practitioners for declining the influenza vaccination. This evaluation occurs at least annually.
8. The organization improves its vaccination rates according to its established goals at least annually. (See Standards PI.02.01.01 and PI.03.01.01)
9. The organization provides influenza vaccination rate data to key stakeholders which may include leaders, licensed independent practitioners, nursing staff, and other staff at least annually.
The Joint Commission provides a number of educational and information resources for healthcare professionals about influenza vaccination, including:
• HAI Portal: http://www.jointcommission.org/topics/hai_influenza.aspx
• Influenza and Influenza Vaccination Myths and Realities: http://www.jointcommission.org/assets/1/6/JC_influenza_myths.pdf
• Strategies for Improving Health Care Personnel Influenza Vaccination Rates: http://www.jointcommission.org/assets/1/18/Strategies_-__Improving_Health_Care_Personnel_Influenza_Vaccination_Rates.pdf
Joint Commission. R3 Report. Influenza vaccination for licensed independent practitioners and staff. Issue 3, May 30, 2012. Available at: http://www.jointcommission.org/r3_issue3/
U.S. Department of Health & Human Services. HHS Action Plan to Prevent Healthcare-Associated Infections: Influenza Vaccination of Healthcare Personnel. May 2010. Accessed at: http://www.hhs.gov/ash/initiatives/hai/tier2_flu.html