Overview
We show the overall performance of VA sites regarding vaccinating employees in Fig. 1. We refer to the collective efforts of the different stages to provide the flu vaccine to employees as the “flu campaign”. Also, since all sites implement their “flu campaigns” using a team structure, we refer to all members who are involved as the “team”. We will briefly summarize our main findings here, and will explain in detail in the remainder of the results section. Three factors distinguished sites with high flu vaccination rates from those with low vaccination rates. First, executive leaders were more highly involved in the flu campaign at high outlier sites. They demonstrated visible support, fostered new ideas, facilitated resources, and empowered flu team members. Second, flu teams at sites with high vaccination rates had positive characteristics that included high levels of collaboration among the flu team and across the institution, a sense of campaign ownership, a sense of empowerment to meet challenges, and adequate time and staffing dedicated to the campaign. Third, successful campaigns shared certain strong practices that included advance planning, proactive efforts to make the vaccine accessible to employees, an ability to track employee vaccination status, the use of innovative methods to reach employees with education and promotion, and a use of performance data to guide the ongoing campaign in real time. See Fig. 2 for a summary of these three main findings, which will be described in detail below.
As a further orientation to the reader, Sites 1–3 are high-performing sites, while Sites 4–6 are all low-performing sites. For each organization factor that we identified, we will present findings about high-performing sites first, and then contrast it with our observations from low-performing sites. Italics in quotations signify emphasis by the speaker.
Organizational factor 1: executive leadership involvement
One of our most consistent findings was that executive leadership figures, such as the Chief of Staff, were much more involved with the campaign at the high outlier sites. Their role was pivotal in ensuring the success of the campaign.
At high performing sites, leadership support for the campaign was highly visible, and contributed to a general perception of the campaign being an important priority. For example, some leaders at successful sites engaged in “role modeling” where they demonstrated their support for the campaign by volunteering to administer the vaccine to employees. One interviewee at Site 1 said, “[The nurse executive] makes it a point to volunteer every year to do that”. Leadership figures at Site 3 also participated in giving flu shots. They explained that they do this “So the staff gets the message that it’s important to the leadership to do this.”
At some sites, executive leadership members communicated the importance of the campaign in even more innovative and sometimes lighthearted ways. At Site 2, the Chief of Staff acted in a skit presented to medical center staff which promoted the campaign.
Leadership figures at high-performing sites not only supported the campaign symbolically, but were also involved directly in the campaign in substantive ways. Leadership members secured prime sites to offer the vaccine, authorized symbolic incentives (such as an extra hour of leave) for employees who get vaccinated, and were likely to support new ideas proposed by the flu team. Additionally, at high performing sites, the flu team held frequent meetings with executive leadership throughout the flu vaccination “season” (the autumn) and shared with them the campaign’s progress and needs.
In addition, leadership empowered the flu team and they offered them a wide platform to communicate the importance of the campaign and its progress through town hall meetings and other large events attended by large audiences. For example, at Site 2, leadership figures agreed to offer the vaccine at the staff fall picnic party.
In contrast to the above, there was a lack of visible leadership support at low performing sites. This lack of visibility de-emphasized the flu campaign’s importance as an institutional goal. At Site 5, a low performing site, one interviewee said,
“In short, I think it’s institutional will as well, I mean if the Director says he wants it done then people listen, if the Chief of Staff asks her secretary to send out a notice that there’s going to be employee flu clinic tomorrow then the employees get the notice… [In the absence of this kind of public emphasis]…the employees get the message ‘It’s not that important’… I can guarantee you when the [new unit] reopens at the end of next month, there will be balloons and banners and notices every hour to come by and visit it, and the Director will go there and the Chief of Staff will go there and everyone will know that they consider it to be very important.”
Similarly, the infection control nurse at the same site said “It would be nice to see the Director or the Director of Nursing going out there and encouraging her staff to get the flu vaccine. That would impress me as a staff nurse.”
Furthermore, at low- performing sites, leadership did not remove barriers encountered by the team. At low performing sites, campaigns were beset with red-tape, which resulted in barriers such as difficulty advertising the campaign with promotional banners. One team member (Site 4) remarked,
“I will also say very frankly that …there hasn’t… been the kind of interest that I would like to see from administration about this …I mean it’s mostly a question of can you [leadership]…put some money towards this. And there hasn’t been interest in that…I…suggested could we make a banner, a really nice banner that isn’t…time sensitive…Ya know, ‘Get Your Flu Shots Now!’ that kinda thing and…the response wasn’t like, yeah, great idea”.
In contrast to high performing sites, where leaders approved small incentives for employees to be vaccinated, at Site 6, a suggestion to incentivize employees to get the flu vaccine was rejected by leaders. When asked why, the flu-coordinator explained, “…the leaders of Ambulatory Care; they said, well,…that would require us to organize; we would have to get our staff to make sure that everybody had extra work…and they didn’t want to do it”. A nurse reported difficulties securing a place to give the vaccine “I gotta say we couldn’t even get the room last year because of the basketball game.” [Infection control nurse, Site 5].
Team members at low-performing sites conducted infrequent meetings with leadership, sometimes only at the end of flu season, or no meetings at all, so that there was little involvement of leadership and few opportunities for leaders to help with problem-solving; the flu vaccination team members were generally not empowered to make decisions or take actions to meet the campagins changing needs.
Organizational factor 2: positive flu team characteristics
We consistently observed that flu team members from the high-performing sites worked together closely and communicated often. For example, the occupational health nurse at Site 1 said “I always keep [the infection control nurse] in the loop, so if she needs something…she just emails [me] directly. So…we just work together really closely on a day in, day out basis.” The infection-control nurse at Site 2 said, “we’re [the flu team] pretty much a well-oiled machine…everybody knows their duties” At Site 3, one interviewee said “[my colleague] and I work really well together. She… does a lot of phone calls for me. She will collect data for me…she’ll send out…emails for me as well.” In addition, the flu team at high performing sites established close working relationships with key people across the institution, such as department managers, nursing shifts supervisor, and other flu team liaisons. These contacts contributed significantly to the success in many aspects of the flu campaign, including delivering the vaccine, tracking and reporting employees’ flu vaccine status, and publicizing opportunities to receive the vaccine.
At high performing sites, team members felt a sense of “ownership” over the flu campaign, and served as its personal representatives to front-line staff. At Site 3, the occupational health nurse said, “So basically, my whole idea is, I have a sense of ownership of this…it’s like mine and I feel that, I own it, so I focus this energy on getting the results I want…”. Similarly, at Site 2, the education nurse proudly associating her figure to the flu campaign said that she is called “the flu queen” at her institution. She said, “I mean, I’m sure people when they see me in the hall, they picture me as a walking flu shot”.
Additionally, team members at high-performing sites were creative, and felt empowered to find solutions to challenges. They were characterized by a tenacious effort that often required going beyond the call of duty. One member of the flu team at Site 2 stated that her colleagues’ efforts on behalf of the campaign made it into a great success: “…the hard work that our employee health nurse puts into it and our health promotion disease prevention person puts into it. They really get out there and they talk with staff and they try to promote that vaccine.”
Finally, high-performing sites had the flexibility to dedicate staff and time for the campaign, allowing them to spend most of their time on the campaign during the flu-vaccination season. When we asked an occupational health nurse at Site 3 about how she manages her time during the flu-season, she replied,“… on my schedule, I’ll block off like one day a week or two days a week. Those are my flu days. So no one can schedule anything on those days, and then the other three days of the week you can schedule my pre-employment physical exams…”
In contrast, at low-performing sites, teamwork was generally absent. At most low performing sites, one department or one person was responsible for the entire campaign, while others served in a peripheral role. The infection-control nurse at Site 4, when asked how much time she spent on the campaign, replied, “No, not much at all. I wouldn’t have even put it down on my resume were I to write a new one. I’m just consulting with occupational health.” Similarly, at Site 6, the flu-coordinator said, “…we’re distant from each other and it’s sometimes hard to organize a system-wide campaign because…there are so many disparate parts”.
Sometimes, team members expressed frustration at being asked to run the flu campaign alone, and wished that others would be more involved. The flu-coordinator at Site 6, speaking of infection control, said, “I really believe they could’ve been more involved but they are consultative only, according to them.” Similarly, at Site 4, the occupational health nurse said: “I don’t think it’s seen as a hospital-wide responsibility. I don’t think the culture here is, that it’s really…a big subject for some reason.” In contrast to high-performing sites, where flu team members had strong connections and working relationships not only with each other, but also with key contacts across the organization, such contacts were absent at low-performing sites.
Furthermore, in contrast to the high-performing sites, we observed a lack of a sense of “ownership” of the campaign by team members at lower performing sites. At Sites 5 and 6, we found that there was no consensus about who should spearhead the HCP flu campaign. At Site 5, the person formally assigned to champion the HCP flu campaign was not aware of his role. At Site 6, the assigned nursing department for this task did not view the HCP flu campaign as part of their role. The flu-coordinator at that site described it as, “this flu campaign was kind of the [unwanted project]. Nobody wanted to do it.” She also noted that there is a lack of accountability when assigning a task, leaving the burden of achieving the task on one person.
“…, we did have [a] department accept a task at one point in time…I recall just having to stay after them week after week after week to say is this done, is this done? And it never got done, so I ended up picking up and doing it. …so it’s the accountability piece of it and making sure that one person is not just the only individual running around and working.”
In contrast to the positive attitude of team members at high-performing sites to manage the flu campaign, team members at low-performing sites focused on external factors as explanations for their low vaccination rates, such as the culture of their geographical region, mild flu-seasons, and the absence of a mandating policy for the flu vaccine. There was a sense of helplessness; respondents had difficulty imagining what could improve their performance. The Chief of Staff at Site 5 said:
“…it’s really hard to single handedly overcome public perception which I think is really what we’re looking at here. There’s a high percentage of the public population that don’t get the flu shot when the flu’s not around, and they think they get the flu when they get the shot so, I think this is a nationwide issue, not just a VA issue. So until we can mandate [that all employees must be vaccinated], I think it’s gonna be really hard.”
This participant identifies several possible explanations for why his site’s campaign is doing poorly year after year; tellingly, none of these factors is amenable to change.
While at high sites, the flu team was had the flexibility to spend considerable time and effort on their campaign, especially during the vaccine season, at low-performing sites, team members were expected to continue the same work productivity during the vaccine season as they do the remainder of the year. The flu-coordinator at Site 6 said:
“I do a lot of things. I’m in charge of the inpatient performance measures. I’m in charge of the…nurse practitioner practice here. We have a hundred and five NP’s here. Uh, this is a collateral assignment. I also hold a panel of patients in cardiology.”
When we asked if she can designate time to work on the flu campaign, she responded, “I can’t, because I just look at what’s a priority and I go with it… ”
Similarly, members of the flu team at low-performing sites felt the amount of staff effort devoted to the flu campaign was inadequate. The hospital epidemiologist at Site 5 said, “There is always a tug and a pull between what they’re doing and what they are able to do, and I do think that they [the flu team] are understaffed for a hospital of this size”. The flu Manager at Site 6 stated, “We don’t have designated staff to give vaccination. It’s whoever’s on light duty; whoever has a foot that’s in a cast and can’t really walk, whoever’s pregnant…flu is not considered a very high priority by this institution” [italics for emphasis].
Organizational factor 3: strong practices
Each site’s HCP flu campaign varied based on various idiosyncratic factors, such as the number of off-site campuses, the geographic size of the campus, and the number of HCP’s that had to be reached, among other issues. However, despite these local idiosyncrasies, we identified 5 strong practices that were consistenly present at high sites and absent at low sites.
Strong practice 1: advance planning
High-performing sites did more advance planning in preparation for the flu vaccination season. Sites 1 and 2 used hospital-wide events, such as emergency drills and annual picnics, as an opportunity to reach large numbers of employees. Extensive advance planning was required to set locations and schedules in partnership with different departments at their institution. As another example of strong advance planning, Site 2 developed an action plan detailing the role of each team member in the flu campaign. This plan serves as a guide to assign tasks that need to be accomplished by a predetermined deadline. It includes times for regular, fixed meetings and a reference for troubleshooting problems. In contrast, this sort of detailed and proactive advance planning was absent at the low performing sites.
Strong practice 2: making the vaccine easy to access
High-performing sites had multiple avenues for delivering the vaccine for longer periods of time. For example, Site 1 provides walk-in clinics that are open 3-4 times a week, including weekends, from 9:00 am to 9:00 pm, from October through December. Also, the flu vaccine is offered during an annual emergency drill for one week, from 9:00 am–9:00 pm. Departments participate in the drill according to pre-arranged times, but individual employees can also attend and get vaccinated. Moreover, flu “blitzes” are scheduled and coordinated between the occupational health nurse and designated “health liaisons” for off-site campuses. Site 2 similarly offers the flu vaccine during the fall staff picnic time. They also seize unscheduled opportunities to offer the vaccine using time scraps, announcing their availability and location using the hospital address system.
Low performing sites offered the vaccine in a less frequent and intense manner compared to high performing sites. In addition, low performing sites did not integrate their campaigns with other large hospital activities.
Some modalities of vaccine delivery appeared to be used both by high- and low-performing sites, such as walk-in clinics, staff vaccinating each other, offering the vaccine at large staff meetings and using the rolling carts. Because they were present at both high and low sites, these modalities did not appear to distinguish between high and low performing sites. Indeed, these modalities were the only ones employed at the low performing sites, as well as site 3. However, Site 3 offered them more frequently and over longer time periods, which presumably contributed to the improved results.
Strong practice 3: tracking vaccination status of individual employees
All facilities had access to an electronic system that allows them to monitor vaccination rates at the instituational level. However, only high-performing sites had effective processes to track the vaccination status for each individual employee. A record was kept and updated for individual employees who received the vaccine or declined it. High-performing sites actively encouraged employees to report their vaccination status, so that they could enter it into this tracking system. Also, combining the flu vaccine with a mandatory emergency drill provided a convenient opportunity to collect employees’ vaccination status en masse. Following that event, flu team members at Sites 1 and 2 contact local managers, who then assume the responsibility to contact employees whose vaccination status remains unknown and communicate that status to the flu team. This process was repeated weekly or bi-weekly throughout the vaccination season. Similarly, at Site 3, the occupational health nurse generates a list of employees and tracks employees whose vaccination status remains unknown. This process was reinforced by a local policy that requires signing a declination form by those who refuse the vaccine.
Low performing sites lacked any organized process to track employees’ vaccination status. Without knowing the vaccination status for employees, it was difficult to target extra efforts to those who had declined the vaccine or who simply had not had an opportunity to receive it.
Strong practice 4: innovative promotion and education methods
At high-performing sites, the team invested time and effort in educating staff about the flu vaccine, even if they ultimately refused vaccination. Site 2 was innovative in promoting the flu campaign, creating humorous themes that change annually, and holding a contest for best flu-videos. When we asked the infection-control nurse about the value of this, she said “We make it a topic that employees talk about.” Both Sites 1 and 2 provided an opportunity for personal counselling for employees who refuse the vaccine. Such activities took place during massive vaccine campaigns, allowing the flu team to incorporate targeted material that addresses some of the misconception about the vaccine and apply advanced techniques, such as motivational interviewing, to resolve ambivalence about receiving the vaccine.
Low performing sites simply relied on prepared educational material that was mostly supplied by the national VHA Office of Public Health, and did not develop targeted or humorous materials at the local level. Educational materials used at low performing sites lacked innovation that would engage employees and increase their interest in the flu campaign.
Strong practice 5: performance audit and feedback by department
Only high-performing sites provided a mechanism to share vaccination rates with employees. At Site 1, department managers receive weekly or bi-weekly updates of vaccination rates in their units, which are shared across the facility. This pressured local managers not only to track vaccination rates but also to urge employees to receive the vaccine. One manager at Site 1 explained “now I’m in a competition too, because all the managers’ units are listed, you don’t want everybody at the medical center to have 99 % and [you have less]”. At Site 3, the Director emphasized feedback as key to his site’s success. “…giving them feedback about how we are doing compared to others nationally and also within our [region] is key.”
Low performing sites did not have a process to feed back vaccination rates to unit managers or employees. This may have been expected, since there was no process to track employee vaccination status, which would have been necessary to produce such a report.