Facilities Involved in Vaccinations QIA

Network 1 Network 2 Network 6 Network 9

Goal is to improve vaccination rates in participating facilities.

Project Guidelines

IPRO ESRD Networks will be implementing CMS designated activities with facilities chosen for this activity to increase rates of pneumococcal pneumonia and hepatitis B vaccinations at the facility level. Facilities will be provided with root cause analysis (RCA) templates that the Network will review with the project lead to develop a Plan Do Study Act (PDSA) Plan for improving rates of pneumococcal pneumonia and hepatitis B vaccinations.  The project will be conducted beginning in April 2016, and will end September 2016.  Facilities must increase their vaccination rate by a minimum of two percent for both vaccinations by September 2016 and facilities that do not meet the vaccination rate >60% will continue into the project for the next calendar year (2017).

Project Timelines

April 2016

  • The Network will provide a notice of participation in this activity, as well as a template for evaluating the root cause analysis of low vaccination rates for pneumococcal pneumonia and hepatitis B
  • Facilities will use the provided RCA template to review both vaccination rates with the interdisciplinary team during QAPI meetings and return it by April 15, 2016. The Network will conduct a webinar at the end of April to (1) Review the RCA findings and to (2) discuss identified interventions related to the RCA.

May – September 2016

  • Facilities implement interventions and provide a summary report to the Network on a monthly basis by email or fax of any key observations discussed during monthly QAPI


Vaccination QIA

Initiative Contacts

Network 1 (CT,ME,MA,NH,RI,VT)
Brittney Jackson, LMSW, MBA

Network 2 (NY)
Anna Bennett
Community Education Coordinator

Network 6 (GA, SC, NC)
Anna Bennett
 Community Education Coordinator

Network 9 (IN, KY, OH)
Andrea Bates, LSW, MSW
Patient Services Director