Healthcare worker immunization is an essential component of disease prevention. Missed work due to illness creates a hardship for employees and facilities. The following best practices can help your facility more fully comply with this standard. An important aspect of this measure is preparation. Begin early in the year to evaluate last year’s performance and put in place measures to improve the upcoming immunization cycle.


Employee Management/Human Resources

• Vaccinate current employees at Annual Health or Skills Fair
• Immunize upon hire (during season)
• “Rounding” by Employee Health/Infection Prevention Nurse to vaccinate
• Perform all employee evaluations during September-December, tying presence of vaccination to annual performance review
• Provide incentives to employees for getting vaccinated during October (may include September with appropriate flu vaccination for that season)
• Require physician letter supporting declination for health concerns
• Organize campaign to provide vaccinations on all shifts/weekends
• Target attempts to reach PRN staff


• Establish and implement a policy requiring all healthcare personnel be immunized as defined by MBQIP measure.

This policy should contain:
a. Requirement of face to face counseling for employees who decline the vaccine
b. Requirement of a signed declination from staff without medical contraindication
c. Requirement of the use of face mask for unvaccinated employees


• If using EHR, engage IT requiring up-to-date vaccination prior to log-in


• Include compliance for provider vaccination through medical staff by-laws, use of provider peer review and through granting hospital privileges

Use of Data/Concurrent Review Tactics

• Consider use of THAF/ARCHI flu tracking spreadsheets (Appendix B)
• Coordinate Human Resources to provide Employee Health/Infection Prevention with lists of current employees, monthly, beginning on October 1st through March 31st. It is permissible for staff receiving vaccinations in September to be included in the count beginning October if they have received the flu vaccination for that season. Staff not receiving vaccinations are scheduled for face to face follow-up with EHR/IP for vaccination or reason for declination, as appropriate.
• Provide Data reports (daily, weekly) to staff and C-Suite
• Review in Huddles the data for the measures and ways to capture employees for immunization.


Karen Kendrick, director of clinical initiatives and quality, 512/465-1091

The resources included in the toolkits are offered as examples and do not constitute expressed or implied endorsement by the Texas Hospital Association Foundation.


Over 3 million people get infected with the flu each year. Nosocomial infections from community acquired infections can increase hospital lengths of stay and even result in death. The Centers for Disease Control (CDC) and the Center for Medicare and Medicaid Services strongly recommend facilities develop a process for screening, educating and immunizing patients entering facilities seeking care and treatment.

This measure evaluates the facility’s effectiveness in screening and offering influenza vaccinations to their patients. Below is a list of best practices for implementation and reinforcement of this measure which is evaluated with discharges beginning October 1st and running through March 31st.


• Make plans with Nursing, Pharmacy and Physicians on upcoming immunization campaign for eligible patients.
• Begin educating the staff on the Immunization Campaign for patients in the summer with a major communication the week before October 1 to assure readiness on October 1st for appropriate screening and vaccination.
• Establish a nurse-driven standing order or protocol which allows for screening and administration of vaccine to all eligible patients without a physician’s order (See Section on Physician Orders).
• Collaborate with pharmacy to have vaccine available in ED and Inpatient units.
• Identify strategy to address patients who decline.
• Consider use of THAF/ARCHI flu tracking spreadsheets (Appendix A)
• Conduct daily review of patients’ administration status (see form below) (See printable form in Appendix B - IMM-2 Quality Audit Checklist
• Review status at discharge for completeness (see form below) (See printable form in Appendix B - IMM-2 Quality Audit Checklist

Physician Orders/Standing Order Sets

Develop Standing Delegated Medical Orders for Immunizations on all patients seen in ED or Inpatient (See Appendix C)

• Another resource
• Add order for “Immunize on Admission” to all Admission order sets


• For those hospitals on an electronic health record, work with your IT department/vendor to develop a Best Practice Alert to fire on admission, every 12 hours and upon discharge.
• Embed assessment or prompt in EHR/paper medical record

Concurrent Data

This measure is best managed for concurrent review while the patient is hospitalized. Daily review of the patient’s status during huddles and nursing shift to shift reporting will best facilitate monitoring and action for each eligible patient.

Appendix A provides tracking forms (manual or electronic) to collect and analyze your performance in immunizing patients in real time.

• Consider use of THAF/ARCHI flu tracking spreadsheets (Appendix A)

Quality Audit Form for Concurrent Review of Patient’s Immunization Status

Another alternative to collect quality data in real time is the use of the audit form. The goal for any improvement effort is for the necessary processes to be hard-wired into the daily regimen. To assist in hard-wiring the process for screening and vaccination, develop a plan to ensure all patients are screened at each shift until the measure has been fulfilled. Knowing that hospitals are complex environments, forms are often helpful to drive compliance. The sample form (Appendix A IMM-2 Quality Audit Checklist), could become part of the admission paperwork and attached to the front of the chart during ED Visits and on admissions to the facility. This form should not become a part of the patient’s medical record but should be forwarded to the quality department upon discharge of the patient to help the quality department monitor concurrent compliance and reporting. (See Appendix B IMM-2 Quality Audit Checklist)


Community Involvement

• Partner with local voting precincts to give flu vaccinations to those arriving to vote.
• Provide each participant with a card indicating they have received the immunization
• Partner with local physician offices, long-term care facilities, home health agencies and community health clinics to host an immunization fair and to develop methods to receive patient immunization records when patient is admitted.

Toolkit Appendices:

Appendix A - THAF/ARCHI IMM-2 Tracking Forms (Manual or Electronic)
IMM-2 Inpatient Flu Oct2017 To Mar2018.xlsx
IMM-2 Inpatient Immunization Status Form - 2017 Oct.docx
IMM-2 Monthly Summary Form - 2017 Oct.docx

Appendix B - Quality Audit Checklist (IMM-2)

Appendix C - Sample Policies from CAHs/Other Sources on Medical Staff Standing Orders
Implementing Standing Orders in Medical Practices, Immunization Action Coalition
Administering Influenza Vaccination, Immunization Action Coalition
Inpatient Influenza Immunization, Memorial Medical Center
Inpatient Pneumococcal, Influenza Immunization, Ward Memorial Hospital
Administering Influenza and Pneumococcal Vaccine, Medina Healthcare System

Templates, Policies, Processes
Consent for Influenza Vaccination, Palacios Community Medical Center
Healthcare Personnel Safety Flu Vaccine Protocol, CDC NHSN
Hospital Policy & Protocols for Influenza & Pneumococcal Vaccination, Sample, Immunization Action Coalition
Influenza Consent Form, DSHS

Best Practices:
Flu Activity and Surveillance, CDC
Influenza Vaccination Information for Health Care Workers, CDC
Immunization Record Card, DSHS
Immunization Record Cards, Immunization Action Coalition
Immunization, information sheet, TMF Quality Innovation Network
Implementing Standing Orders in Medical Practices, Immunization Action Coalition
Improving Influenza Vaccination Rates among Health Care Workers, TMF Quality Innovation Network
Influenza Vaccination Information for Health Care Workers, Influenza, CDC
Influenza Vaccine Information Statement, CDC
Literature and Forms Online Order Form, DSHS
Recommended Immunization Schedule, 0-18yrs, CDC
Recommended Immunization Schedule for Persons Aged 0 through 18 Years, CDC
Strategies to Increase Staff Immunization, TMF Quality Innovation Network
Surveillance for Healthcare Personnel Vaccination, CDC
Vaccine Information for Adults, CDC