Incentives Prompt High Health Worker Flu Vaccine Acceptance

Daniel M. Keller, PhD

October 26, 2012

SAN DIEGO, California — A "carrot and stick" approach, in which incentives and subtle social pressure were combined, increased the rate of influenza vaccination among healthcare workers in a large hospital system. Even without a mandate, more than 90% of workers were vaccinated, Marci Drees, MD, MS, DTMH, infection prevention officer and hospital epidemiologist at the Christiana Care Health System in Newark, Delaware, told delegates here at ID Week 2012.

The US Centers for Disease Control and Prevention has recommended for more than a decade that all healthcare workers be vaccinated for influenza, but national rates remain below 70%. Mandating immunization has not solved the problem, so the Universal Flu Task Force at Christiana Care took a different approach for the more than 10,000 nonunion employees of the 1100-bed academic, community-based system.

Planning for the 2011/12 season started in April 2011. The task force initially drafted a policy for mandatory vaccination and strict enforcement, but the hospital chief executive officer was reluctant to implement it and asked them to put it on hold.

The revised plan made it easy and convenient to be vaccinated, used peer pressure to encourage it, and made the vaccination rate a component of hospital-wide bonuses. A "flu blitz" campaign was rolled out in October 2011, vaccination stations were set up at the main entrances to the system's 2 hospitals for 5 days, covering all shifts. Ancillary sites were set up during the second week. Nurses and pharmacists did the injections, clerical staff pitched in, and senior leaders were intentionally highly visible.

The information technology (IT) department developed a tracking system using bar-coded paper forms to monitor consent, refusal, and exemption. The forms and employee identification badges could be quickly scanned when employees presented at the entrance stations or Employee Health Services (EHS).

All employees had to submit consent, refusal, or exemption forms by November 30. Weekly reports went to managers and senior officers listing the vaccination status of all employees and whether they had submitted a form. Those who didn't submit a form by the deadline were subject to disciplinary action. All employees were subject to the policies, whether they had direct patient contact or not.

Once vaccinated, employees received a hang tag for their badges saying, "I'm vaccinated." Any employee not wearing a tag had to wear a mask in any patient care area. This move "dramatically increased visibility and peer pressure," Dr. Drees noted.

A strong incentive to get vaccinated was an employee bonus system, which had been in place since 2009. Bonuses were based on 3 metrics — financial, patient satisfaction, and patient safety. The patient safety metric was based on the reduction in hospital-acquired infections in the previous year.

Dr. Drees explained that the patient safety metric was modified to include the employee vaccination rate. The minimum rate for a bonus was above 75%, and an additional payout was made if the rate reached 80% or 85%. In previous years, a successful patient safety metric led to bonuses of $800 to $1200 per employee, which was "highly motivating for employees," she noted. All employees in good standing were eligible for a bonus.

Results Exceeded Goal

The vaccination rate at Christiana Care went from 66% to 92%, exceeding the tiered bonus top figure of 85%, Dr. Drees reported.

The majority of employees were compliant with the policy: 92% were vaccinated, 1% (n = 126) were exempted for medical or religious reasons, and 4% (n = 445) refused to be vaccinated. Of the employees who refused to be vaccinated, 29% said they did so for safety reasons, 27% said they never get the flu, and 26% said they believed they could get the flu after being vaccinated.

In general, the vaccination stations were well received, with 85% of the staff viewing them "positively" or "very positively." In the first 2 weeks of the campaign, 7275 people were vaccinated.

The 2011/12 campaign cost $172,152, which is $62,780 above the cost of vaccine and miscellaneous medical supplies, and does not include the cost of additional EHS personnel. The added costs were for badge hang tags, communication and advertising, nursing overtime, and IT support.

Dr. Drees said that it remains to be seen if such a program and its effects will be sustained over time. She explained that nonemployee physicians (such as those in part-time teaching positions) are subject to the policy, but tracking, incentives, and disincentives do not apply to them.

Session moderator James Crowe Jr., MD, professor of pediatrics, pathology, and microbiology and immunology and director of the Vanderbilt Vaccine Center at Vanderbilt University in Nashville, Tennessee, who was not involved in the study, told Medscape Medical News that vaccination stations make the process and compliance easy.

"If you make this a positive social activity and make it very, very easy with minimal time in line and minimal paper work and documentation," you get compliance, he said.

Check-in at the site took about 30 seconds, minimizing the overall encounter time. "The expectation that this is routine, normal, and that everybody coming in the building is going to get it [helps]," Dr. Crowe pointed out.

He said conventional programs relying mostly on education and publicity do not work very well and achieve compliance rates of only about two thirds. Mandatory systems with potential termination can do much better but are not ideal.

The nonmandatory strategy used, with it's strong financial incentive, allowed them "to boost their compliance very dramatically," Dr. Crowe said.

The use of badge tags indicating who has complied and who has not "has a strong social pressure.... One could imagine it as sort of a reverse scarlet letter. If you're not wearing your badge, you're really endangering a $1000 bonus to your peers," Dr. Crowe said.

Dr. Drees and Dr. Crowe have disclosed no relevant financial relationships.

ID Week 2012: Abstract 96. Presented October 18, 2012.

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