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Running head: NEEDS ASSESSMENT

Quality/Safety Needs Assessment

Lisa A Morrill
Ferris State University

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Abstract
When perusing healthcare media the topic of quality of care and increased patient safety
is one of the most abundant subject matters available. Healthcare has been challenged with
finding ways to make hospitals safer places for the consumers. Mandatory influenza vaccine
should be considered one of those safer practice measures. Many regulatory and advisory groups
have already taken a stand on the topic of requiring healthcare workers to receive an annual
influenza vaccine as a condition of employment. This paper will attempt to support the process
of requiring an annual influenza vaccine and describe important change concepts that must be
considered prior to developing a program.

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Quality/Safety Needs Assessment

In the organization that I currently work the issue of mandatory influenza vaccination for
the healthcare worker has been discussed and dismissed over the last few years. Trends in
healthcare support the standard of requiring immunization for all healthcare providers with an
annual vaccine for influenza. Although much controversy surrounds the mandate of the annual
vaccine, studies show that receiving the vaccine does help decrease the transmission of influenza
illness.
In an attempt to provide a decrease in influenza transmission to our patients as well as all
others that a healthcare worker would come in contact with namely their peers and family,
annual influenza vaccination has been encouraged for the healthcare worker since 1984
(Babcock, Gemeinhart, Jones, Dunagan & Woeltje, 2010). Additionally, Healthy People 2020
has set a targeted goal that 90% of healthcare workers be immunized with the influenza vaccine
(The National Vaccine Advisory Committee, 2012).

With many hospitals mandating healthcare

workers receive a vaccine or provide an acceptable reason for declination as a condition for
employment, healthcare leaders will be looked upon for direction and backing. This paper will
explore some of the supporting evidence toward mandatory influenza vaccination, and discuss
concepts that should be considered during implementation of a mandatory influenza vaccination
program.
Identified Issue
Healthcare leaders of today are faced with the challenge of providing a higher
quality and safer level of care to the population that they serve. Marshall (2011) encourages
leaders, to look beyond the work activity to the vision and meaning of improving lives and
promoting healing ( p. 137). Marshall also describes that a leader must likewise have

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involvement in managing concepts related to risk in the healthcare environment (2011). This
risk may include the entire organization, the employees as well as the patients. Evidence does
show that an annual influenza vaccination decreased the likeliness of transmission from one
person to the other (Poland, G.A., Tosh, P. & Jacobson, R.M., 2005).

Healthcare institutions

are recently challenged with the need to provide a safe place for patients to receive healthcare.
Using the above evidence it can be assumed that employees who have not received an annual flu
vaccination are at risk for spreading influenza to the patients that they care for as well as
harboring an increased risk for transmission from others. Studies provide evidence that
healthcare workers in the United States have a low acceptance rate for influenza vaccination
which is documented with rates as low as 35%40% (Center for Disease Control and Prevention,
2005). At this time the Centers for Disease Control and Prevention (CDC) only stands at the
recommendation that influenza vaccine should be given to the healthcare worker, they have yet
to recommend it become mandate (CDC, 2011).
Now, with the evidence above and the strong push to mandate annual influenza
vaccination for the healthcare provider I believe its imperative to look at the history of
healthcare worker vaccinations. Employers have already mandated proof of immunity on hire
for several vaccine preventable diseases such as Measles, Mumps, Rubella, and Varicella to
name a few, if immunity is not evident a booster vaccination is given. These too, are mandated
to help prevent the transmission of preventable diseases between the patient and the caregiver.
In light of this knowledge how can we ignore the push to mandate influenza vaccine or an
accountable practice alternative for the healthcare worker?

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Model Evaluation
Making change in an organization requires the use of many different approaches that can
be found in a plethora of articles, research studies and models of care. For the purpose of this
paper, evaluation and consideration of the principles of high reliability standards, just culture and
quality improvement models were to help guide our direction. Each one of these models has
different points that help make positive strong organizations yet they also share some common
traits.
High reliability organizations (HRO) can be defined as an organization that has
succeeded in avoiding catastrophes in an environment where normal accidents can be expected
due to risk factors and complexity (Wikipedia, 2013). Some of the documented characteristics
of an HRO include being sensitive to operations, reluctant to accept simple explanations, having
a preoccupation with failure, deferring to expertise and being resilient. Some of the concepts
that could be related back to this proposal would be those of looking at processes that arent
working, listening to the experts and communication. The documented rates of healthcare
workers influenza vaccine acceptance provides the proof that rates are lower than expected.
With goals set for 90% acceptance rates, a process is necessary to increase workers acceptance of
the vaccine, something has to change in the provision process to reach these hefty goals. In this
proposal I plan to talk to staff and use their knowledge and perceptions to educate and encourage
vaccine acceptance. A sense of urgency would be developed to assist in communication and
create buy in as well as an understanding in the need for change.
A Just Culture can be referred to a way of safety thinking that promotes a questioning
attitude, is resistant to complacency, is committed to excellence, and fosters both personal
accountability and corporate self-regulation in safety matters (GAIN Working Group, 2004, p.

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E4). I look at this definition in a way that it supports system safety by looking at ways to
promote a no blame culture while working towards ways toward prevention of safety issues from
occurring again. In other words, a way to promote higher levels of safety by finding solutions to
occurrences of potential risks for our patients. This type of environment encourages
organizations to look at potential safety issues and work toward a higher level of safety; in this
case transmission of influenza which could be risk for our patients and then development of a
process should be implemented towards prevention of said transmission. Identifying the
increased risk and open communication from all stakeholders can help to create the sense of
urgency and support the proposal toward mandatory influenza vaccine in this type of
organizational culture.
While researching quality improvement models the following quote was supportive of
my proposed plan, knowledge for improvement; learn to combine subject manner knowledge
and profound knowledge in creative ways to develop effective changes for improvement
(National Initiative for Childrens Healthcare Quality, n.d.). Using the statistics provided and the
subject knowledge presented, it further supports the need for an annual influenza program to
increase the quality of care and level of patient safety in a healthcare facility. Additionally, it will
also assist in meeting the targeted goals of 90% acceptance.
Several common denominators can be seen when looking at strong and effective
organizational models, being open to continual quality improvement, use of successful change
strategies and communication. I believe that communication is probably the most important.
Staff needs to be kept informed on the scope of the entire organization, they need to have
knowledge to make informed decisions and they need to be encouraged at being vested in the

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daily operations and future endeavors to help develop a trusting, knowledgeable and supporting
relationship with the organization.
Proposed Plan
My goal for this project would be to make annual influenza vaccines mandatory for
healthcare workers in our organization. I understand that not all workers would be able to accept
the vaccine for potential reasons such as a medical contraindication, an allergy or even religious
motives. Studies are consistent with the belief that employer mandated vaccination would more
likely be accepted by healthcare workers therefore increasing the rates of vaccination in an
organization (Lubbert etal, 2014). The recent hospital merger in our organization has provided us
with new resource potential. Our main campus has already taken the stance on annual vaccine
and has made it mandatory for all staff as a condition of employment. So as not to reinvent the
wheel, I would like to collaborate with employee health staff from the main campus to use the
process that has already been established. Access to their policy, paperwork and cultural support
tools will assist in implementation at our facility.
I believe that communication and education will need to begin early and remain strong
through the entire change process. The primary role of leadership in this step is to make the
need for change apparent to the entire organization...to make everyone involved see and feel the
need to change (Cohen, 2005, p. 20). The staff barriers to accepting the influenza vaccine
would need to be identified and addressed towards the proposed change. Leaders should
anticipate what reasons staff give for not accepting the vaccine and begin education in hopes to
dispel any myths or concerns. Consequences and acceptable denial reason should be outlined
and communicated and practice changes defined for those with acceptable reasons for
declination.

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Immunization clinics would need to be scheduled and held at times convenient for all
staff members. Documentation options would need to be reviewed and developed to ensure
capturing necessary data on both the acceptance side as well as the declination side in attempt of
capturing necessary information for required data submission. The Centers for Medicare Services
now requires that healthcare workers influenza immunization rates be submitted and will
ultimately capture regional trends on the yearly uptake of the vaccine, prophylaxis and treatment
for healthcare personnel, as well as the elements within yearly influenza campaigns that succeed
or require improvement (Department of Health and Human Services, 2011, p. 51632). It goes
on to also
describes the importance of influenza as a public health issue, the importance of
protecting vulnerable patients from influenza infection, and the importance of influenza
immunization as part of a comprehensive influenza infection control program for
protecting both healthcare personnel and patients against influenza infections
(Department Health and Human Services, 2011, p. 51634).
Ethical Implications
The requirement of mandatory influenza vaccines has been seen as a controversial issue.
The trend toward requiring an annual influenza vaccine is debated with the introduction of bills
for and against, law suits in argument of and strong support from large advisory groups both pro
and con, however the potential for increased safety for all of healthcare customers is a strong
support in favor of mandatory vaccines. As well as the legal side of ethical implications, the
basic civil ethical side should also be considered. There are many considerations that should be
evaluated prior to embarking on a mandatory program and these should be identified and studied
prior to the mandate. In an additional article on what every hospital should know before

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implementation of a mandatory influenza vaccine program the attorney at law urges hospitals to
keep in mind that there are several issues to consider prior to mandating a program (Swank &
Longo, 2011). Cited are main points to consider, union concerns, civil liberties, consequences of
those not willing to comply and identification of those staff members that will be included in the
mandate (Swank & Longo, 2011). Although valid arguments can be cited both pro and con
towards mandating annual influenza vaccination for all healthcare workers the debate has yet to
prove that mandating an annual influenza vaccine will provide any more of a safety net for
customers than allowing the healthcare worker to determine their own vaccination status.
Evidence does show some truth behind the question of decreasing influenza transmission
through healthcare workers but is it enough to take away the rights for each individual to make
their own informed medical decisions? Requiring an employee to receive an annual vaccine as
part of their employment process opens the door for many potential questions and issues that
must be addressed prior to supporting a mandatory program.
Summary
In summary, leading change is an ongoing process while performing in a role of a nurse
administrator. The scope of practice for a nursing leader is being forced by the initiatives
required to meet the demands of governing bodies. Although mandatory influenza vaccine has
yet to become mandate, the trends and recommendations from advisory groups are leading in
that direction. This proposal is an initiative towards development of a mandatory program in my
organization. Through the course of this change process it is imperative to create a sense of
urgency, involve staff in the process and work to dispel the complacency that can often be found
during a change project. Advisory agencies have also challenged healthcare institutions to
transform cultures into more collaborative customer focused care organizations to help promote

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higher quality, safer care for our patients. Influenza vaccines for all healthcare providers can
help to decrease the transmission of influenza between patients and staff, decreasing healthcare
acquired influenza, therefore increasing the level of safe care we provide.

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References
Babcock, H., Gemeinhart, N., Jones, M., Dunagan, C.W. & Woeltje, K.F. (2010). Mandatory
influenza vaccination of health care workers: Translating policy to practice. Clinical
Infectious Disease. 50 (4): 459-464. doi: 10.1086/650752.
Centers for Disease Control and Prevention (CDC). (2011). Immunization of health-care
personnel. MMWR Morbidity and Mortal Weekly Report. 60(RR07), 1-45.
Centers for Disease Control and Prevention (CDC). (2005). Prevention and control of influenza.
MMWR Morbidity and Mortal Weekly Report. 54(RR10), 1-40.
Cohen, D. (2005). The heart of change field guide: Tools and tactics for leading change in your
organization. Harvard Business School Press. Boston, Ma.
Department of Health and Human Services (2011) Recommendations of the Healthcare
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http://www.gpo.gov/fdsys/pkg/FR-2011-08-18/pdf/2011-19719.pdf.
GAIN Working Group. (2004). A road map to a just culture. Retrieved from:
http://flightsafety.org/files/just_culture.pdf.
Gamble, Molly. (2013). 5 traits of high reliability organizations: How to hard wire each into your
organization. Beckers Hospital Review. April. Retrieved from:
http://www.beckershospitalreview.com/hospital-management-administration/5-traits-ofhigh-reliability-organizations-how-to-hardwire-each-in-your-organization.html.
Naleway, A., Henkle, E., Ball, S., Bozeman, S., Gaglani, M., Kennedy, E., Thompson, M.
(2014). Barriers and facilitators to influenza vaccination and vaccine coverage in a cohort
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http://dx.doi.org/10.1016/j.ajic.2013.11.003.

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Marshall, E. (2011). Transformational leadership in nursing: From expert clinician to influential

leader. (1st ed.). New York: Springer Publishing Company, LLC.
National Initiative for Childrens Healthcare Quality. (n.d.). Model for quality improvement.
Retrieved
from:http://www.nichq.org/pdf/Model%20for%20Quality%20Improvement.pdf.
Poland, G.A., Tosh, P., & Jacobson, R.M. (2005). Requiring influenza vaccine for healthcare
workers: Seven truths we must accept. Vaccine. 23. 22512255.
Swank, S., Longo, K., (2011). What every hospital should know before implementing a
mandatory flu shot policy. Health Law Alert Newsletter. Issue 7. Retrieved from:
http://www.ober.com/publications/1606-what-every-hospital-should-know-beforeimplementing-mandatory-flu-shot-policy.
The National Vaccine Advisory Committee. (2012). Recommendations on strategies to achieve
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http://en.wikipedia.org/wiki/High_reliability_organization.

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