NW6 Root Cause Analysis (RCA) Quality Improvement Tool
Vaccination Rates

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.

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* 1. Please select your facility from the dropdown list below (CMS Certification Number (CCN) and Facility name listed)

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* 2. Contact:

Name

Email Address

Phone Number

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* 3. Does your facility offer the following vaccinations?

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

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* 4. What is your current patient census?

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

Pneumococcal (PPV)

Hepatitis B (HBV)

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

Yes

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

Initial Dialysis

Monthly

Quarterly

Semi-Annually

Annually

Other as Needed

Other (please specify)

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

Education on importance of vaccination

Ask the patient why they do not want the vaccine and trend refusals in QAPI

Physician talks speaks with patient

Discuss with the patient why they are refusing

Document in the reason patient refused in Medical Record

Offer vaccine again at a later time

Other (please specify)

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

Yes

If yes: 5A1 - Does it remind you when the vaccination due?

If yes: 5A2 - Does it remind you to offer the patient a vaccination when they have previously refused?

If no: 5A1 - How do you currently manage reminders that a vaccination is due?

If no: 5B2 - Have you considered implementing an automatic reminder system?

If so, how often?

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* 10. Do you track vaccinations in CROWNWeb:

Vaccinations administered at the Dialysis Unit

Vaccinations received at other locations

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

Yes

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

Lack of Patient Education

Patient Social Dynamics (Religious / Philosophical reasons)

Patient Financial Limitations

Non-compliance to follow-up referral

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

Staff education protocol prior to vaccination offering

Staff education protocol when patient refuses a vaccination

Facility systematic process to manage reminders for patient vaccinations

Lack of documentation when vaccine is received outside of facility

Lack of a process to document vaccinations in CROWNWeb

Other (Please explain in #12 below)

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

100% of survey complete.