Five years of mandatory flu shots

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Virginia Mason Medical Center reflects on how it initiated and sustained the program

After reading this article, you will be able to:

  • Describe how Virginia Mason Medical Center initiated and sustained a mandatory flu shot policy
  • List barriers that may arise with a mandatory policy
  • Explain why support from leadership is important

Over the past decade, flu shots have become one of the top priorities for hospitals, especially when the summer months come to a close and flu season approaches.

More recently, however, mandatory flu shots have been at the forefront of a debate between healthcare workers and healthcare organizations. Although hospitals want to improve compliance rates and protect patients and staff members from flu transmission inside the facility, many healthcare workers don’t want to be forced into immunization.

“I think any time you start to say ‘mandatory’ or require something of individuals, I think the initial reaction for all of us is to sort of put on our defenses and cringe a little bit,” says Thomas R. Talbot, MD, MPH, of Vanderbilt University Medical Center in Nashville.

Talbot coauthored a commentary in the September Infection Control and Hospital Epidemiology praising the innovative and sustained approach by Virginia Mason Medical Center in Seattle. For the past five years, Virginia Mason has maintained a mandatory flu shot policy for all employees.

In the first year of the program, the medical center achieved a 97.2% compliance rate. Rates held at more than 98% during the subsequent four years of the program.

Despite pushback from the nurses’ union, less than 0.7% of healthcare workers were granted an accommodation for medical or religious reasons, and less than 0.2% of workers refused vaccination and left Virginia Mason. (Read an opinion piece on mandatory flu shots by clicking here.)

“What they did was, from the top of leadership, said, ‘We think this is a priority, it’s a safety priority, and we are willing to take the arrows that are going to come our way from disgruntled healthcare workers, from unions, because we think it’s the right thing to do for the safety of the healthcare worker and the patient,’ ” Talbot says.

Most recently, Talbot coauthored a revised position paper from the Society for Healthcare Epidemiology of America (SHEA), which was published in the October Infection Control and Hospital Epidemiology.

The position paper urges healthcare organizations to develop a mandatory flu shot policy, with exemptions for those with medical contraindications.

“SHEA views influenza vaccination of HCP [healthcare professionals] as a core patient and HCP safety practice with which noncompliance should not be tolerated,” the paper states. “It is the professional and ethical responsibility of HCP and the institutions within which they work to prevent the spread of infectious pathogens to their patients through evidence-based infection prevention practices, including influenza vaccination. Therefore, for the safety of both patients and HCP, SHEA endorses a policy in which annual influenza vaccination is a condition of both initial and continued HCP employment and/or professional privileges.”

Learn facts about the flu by clicking here.

The first year is the hardest

Any facility that has implemented a mandatory flu shot policy will tell you that the first year is the biggest hurdle, but once you’ve cleared it, employees become accustomed to the policy, and new employees are aware of it upon hire.

“I think, clearly, if you look at the places that it has been successful, it’s that perseverance during that initial year,” Talbot says. “And I’ve talked to some of the Virginia Mason people and they say ‘Gosh, it’s not a big deal. Because we went through the battlefront, we handled that, and now people know.’ ”

The idea to implement a mandatory policy came from a medical assistant, says Joyce K. Lammert, MD, PhD, director of Virginia Mason’s asthma, allergy, and immunology department. Each year, Virginia Mason conducts workshops with employees and patients in which employees from all sectors of the hospital, including doctors, nurses, receptionists, and medical assistants, brainstorm ideas to improve the facility.

“One of our medical assistants had actually reviewed the literature and said, ‘Did you know that healthcare workers’ immunization rates are really abysmal? Why isn’t it mandatory?’ ” Lammert says. “There was this silence in the room as we all looked at each other and said, ‘Wow, that’s a good question.’ ”

By the end of the workshop, the group had brainstormed a number of ideas to improve rates, but it also sent a recommendation to its board asking them to consider a mandatory policy.

“Our board is a community board, so it’s people that aren’t healthcare workers,” Lammert says. “When they looked at it, they were actually shocked at the low rates of immunization for healthcare workers. So for them it was a no-brainer. They couldn’t believe that healthcare workers wouldn’t get immunized.

“Really, the first year was the tough year, and after that, the second year, people pretty much just assumed they would get the flu shot in the fall, and it’s really become a part of our culture,” she adds.

Support from leadership

Initiating a mandatory policy meant getting support from hospital leadership. Additionally, maintaining the policy required continued support from the top down.

“There would have been no way to do what we did without the support of the board and, most importantly, the senior leadership of the organization,” Lammert says. “So our CEO and our president, they were flu champions. They were involved from the very beginning.”

Talbot attributes this support to an established culture within the system. He points to other hospital systems such as BJC HealthCare in St. Louis and Hospital Corporation of America (HCA), which have since followed in the footsteps of Virginia Mason.

“To me that goes to the culture of the institution,” says Talbot. “I think BJC was in the 70th percentile, which a lot of places would love to be at, and they said, ‘This is not good enough.’ And that was the same thing with Virginia Mason and HCA.”

Support from leadership was particularly important when barriers began to arise, such as resistance from the Washington State Nurses Union or from healthcare workers who opposed the mandatory policy. “They were the folks that said, ‘Look, don’t worry about it, we’re doing the right thing because this is all about the patients,’ ” Lammert says. “So I had weak knees, but I would talk to my CEO and I knew it was okay to go forward.”

It also helped that the policy fit well with the strategic initiative of the hospital. On every bulletin board there is a triangle where the patient is placed on top of the priority list.

When leadership looked at the policy from the perspective of worker and patient safety, it was a no-brainer to go through with it, Lammert says.

Timing was a factor

When Virginia Mason finally got approval and implemented the policy in 2005, there was a shortage of flu shots—something that, strangely, was fortunate for the organization.

“It actually gave us a whole year to strategize and go out and talk to our employees and ask them what they needed to know, what the barriers were for them, and then develop a campaign around that,” Lammert says.

Talbot cautions facilities against jumping into a mandatory policy without designing a comprehensive program that includes education efforts and considering the obstacles that may present themselves.

“Right now if you decided today to do it for the current season, it’s going to be a challenge because you really haven’t talked to other stakeholders and had those discussions,” he says.

Dealing with the union

The major barrier Virginia Mason faced during its initial year was resistance from the Washington State Nurses Association. The association won two court rulings in 2006 that forced Virginia Mason to adjust its policy so healthcare workers had to choose between getting a flu shot or wearing a surgical mask during their entire shift.

However, Talbot says that union disputes over mandatory flu shot policies are typically more of a legal battle involving renegotiation and bargaining than an actual stance against flu vaccinations. In fact, 86% of the unionized nurses were vaccinated, even though they weren’t required to get the vaccine while the dispute was being settled.

“That was a thing that was pretty striking when [a doctor] and I reviewed the union’s paper,” Talbot says. “The union challenge is often seen as anti–influenza vaccine, and it’s been used by some of the anti-vaccination groups that way, and I don’t think that really got the gist of it. If you look at the unionized nurses and what their coverage was at Virginia Mason, it’s almost the same as everyone else, which suggests to us that there wasn’t a huge outcry; it was being made to do something that wasn’t negotiated.”

Cost and resources

In their paper, the authors at Virginia Mason noted that they spent a significant amount of money and resources to acquire enough vaccines for everyone.

There were also legal expenses involved in the dispute with the nurses’ union, and time and resources that went toward implementing the policy and educating staff members. (Learn about changes and updates in 2010 APIC influenza prevention and control recommendations by clicking here.)

“I think the first few years it’s going to be more resources—you can’t kid yourself,” Talbot says. “But once it becomes stabilized, are you spending that much more for your program than you had been?”

Lammert points out that although a mandatory program can be financially difficult during the first year, it certainly produces much better results than the time, money, and effort put into voluntary programs that rarely get past 75% compliance. “A lot of institutions spend a lot of time and lot of money on flu campaigns and aren’t nearly as successful,” Lammert says. “So I don’t know that the cost is that much more for use, particularly now that we’ve gotten very good at what we do. So I don’t think that’s a huge barrier at this point.”

Is a mandatory policy the future?

The question that remains about mandatory influenza vaccine policies is this: Will other facilities continue to catch on, making a mandatory policy the future of employment in healthcare?

Thomas R. Talbot, MD, MPH, of Vanderbilt University Medical Center in Nashville, and Joyce K. Lammert, MD, PhD, director of the asthma, allergy, and immunology department at Virginia Mason Medical Center in Seattle, agree that more healthcare institutions seem to be leaning in that direction because of the success that facilities such as Virginia Mason have seen.

“There have been voluntary programs that have gotten over 80%, but not very many and not consistently,” says Lammert. “I’m certainly hopeful that over time other organizations will come along, even seeing our article, and definitely see that it’s something that is doable.”

Talbot believes that most hospitals will have adopted this policy before the end of the decade.

“I think if you look at how in the last few years the number of places that have implemented these policies, even the level of discussion on this as a legitimate policy or even something from a federal standpoint, you can clearly see momentum moving in that direction,” he says. “Whether we end up with that, I don’t know, and I think we’re going to have a thoughtful discussion, but I think clearly, if you look across the United States, the numbers are increasing.”

Does a mandatory policy affect flu rates?

When they hear about a study on mandatory flu shot policies, many healthcare workers want to know whether flu rates decreased along with the increase in vaccination rates.

Unfortunately, the Virginia Mason study does not answer that question, since the study did not include infection rates.

However, Talbot believes that the lack of data does not take away from the five-year study, and that there is enough evidence to prove that flu shots are effective.

“I think it would be nice if we had those outcomes, I know people have said we have never seen those outcomes, but I think if you look at the literature, there are enough studies that have been able to show an impact on healthcare workers that there is biological plausibility,” he says.

Virginia Mason did track absenteeism, although those rates stayed relatively constant throughout the study. But Talbot argues that absenteeism is typically a poor measure of an effective flu policy.

“It’s not just ‘Are you absent?’ There are so many other reasons that go into play with that,” he says. “I was at least encouraged that it didn’t grossly go up, but that’s such a crude measurement.”