TABLE 2

Qualitative Responses From Monthly Diaries

Improvement in Captured Opportunities (No. Practices)Changes in Prompt InterventionBarriers and How They Were AddressedParent ResistanceLessons Learned
25%–30% (3)• Laminated cards, VIS sheet on fluorescent paper, changing wall color sign, door flag• Nursing shortages; intervention improved as staffing improved• Some parents still prefer to defer to the well-care visit, want to discuss with a spouse, or wait until their child is older• Sending frequent reminders every month helped improve outcomes
• Reminders to nurses to review and document• Priority to update new staff and review data• Patient sometimes not accompanied by the primary caregiver; try to obtain phone consent or schedule a nurse visit with the primary caregiver as soon as possible• Improvement occurred when nurse manager helped coordinate the project
• Posted HPV process flowchart• When busy, constant reminders needed to get staff back on track
6%–11% (3)• Laminated reminder signs used to promote the vaccine in the physician’s workroom, using door flags in addition to visits sheets• Staff changes; untrained substitutes assigned to the clinic; no vaccine reminders were provided• Continued resistance from a small minority of parents regarding questions of vaccine safety and necessity• Early, persistent reminders are helpful in long-term change and outcomes
• Editing the note template to improve documentation of refusals and prompt education resources given• When new interns arrived, vaccines were often missed
• Stamps on the printout of the immunization registry to identify that the patient was checked for HPV vaccine need (frequent reminders needed to use stamps)
<5% (2)• Nurse attaches VIS sheet and puts “needs HPV” in intake note• When project champion was out, less prompting occurred• Parents concerned about young age and giving the vaccine to boys, think they can wait; sometimes want to talk to spouse• Generic prompt (review vaccines) had no impact
• Incentivized nurses, reinforced importance• Staff notes vaccine due but doesn’t discuss unless parent asks• Concerns about vaccine safety• Repetition is important
• Nurse puts prompt in intake of EHR• Prompting irregular; depends on staff and how busy it is• QI Team needs to meet more often to initiate changes
• LED light on computer for nurse to turn on• Changing behavior met with some resistance
• Some clinicians sympathized with the parent’s reluctance to vaccinate at a sick visit