Please complete the following dialysis facility information. (One Survey Per Facility CCN)

Definition of Root Cause Analysis: This tool is used to help determine the cause/reasons/specific issues preventing your facility from obtaining the goal of a 60% vaccination rate for Pnuemococcal Pneumonia (PPV) and Hepatitis B (HPV).

Please complete this RCA by February 10, 2017.

* 2. Contact:

* 3. Does your facility offer the following vaccinations?

  Yes No
Hepatitis B Series (HBV)
Pneumococcal (PPV)

* 4. What is your current patient census?

* 5. According to your facility's Electronic Medical Records (EMR), what are your current vaccination rates?

* 6. Do you have standing orders or a protocol for administrating vaccinations?

* 7. When do you offer the vaccinations to the patient?

* 8. If a patient refuses a vaccine, what is done?

* 9. Do you have automatic reminders that vaccinations are due?

* 10. Do you track vaccinations in CROWNWeb:

* 11. Do you request documentation from the patient if they received a vaccination outside of the dialysis unit?

* 12. List the order in which patient barriers most impact your facility's vaccination rates:

* 13. List in order the barriers that most impact your facility's overall vaccination rates:

* 14. Do you have any other comments, questions, or concerns?

100% of survey complete.