Background/Purpose: Pneumonia is a leading cause of morbidity and mortality in the United States among immunocompromised individuals with rheumatologic diseases. Despite the publication of Advisory Committee on Immunization Practices (ACIP) guidelines for pneumococcal vaccinations addressing the specific needs of this population, implementation of these guidelines has been inconsistent. At one Midwestern VA Rheumatology Clinic, pneumococcal vaccination rates were determined to be as low as 3%. From January to June 2018, we used Lean Six Sigma methodologies to improve the current process surrounding pneumococcal vaccination in the Rheumatology Clinic.

Methods: Current processes and improvement targets for pneumococcal vaccine administration were explored using Lean-six sigma methods: 1) interdisciplinary process mapping; 2) process maps analysis, Voice of the Customer (VOC), and brainstorming for value and flow analyses; 3) value stream maps and pilot testing utilizing PDSA (Plan-Do-Study-Act) cycles; and 4) post-implementation control and sustainability planning. The interprofessional team consisted of a nurse and physician leader, a physician champion, and clinic management. The first set of PDSA cycles involved educating providers and posting the ACIP guidelines in each patient room. The second set of PDSA cycles involved bundling and relocating supplies to a more convenient location. Outcome measures were defined as time required to administer vaccine and percentage of eligible patients who are up-to-date with pneumococcal vaccination. Balancing measures included total time spent in clinic and vaccine adverse reactions.

Results: Process mapping revealed eight barriers. Process redesign resulted in elimination of five of these barriers through workflow simplification. A nurse alert step was added to further improve efficiency. The VOC indicated value in the delivery of high quality care and improving vaccination rates, but without spending excess time in the vaccine administration workflow. Interim results show improvement in outcome measures, including reduced time required for vaccine administration from 15 to 7 minutes, and increased percentage of patients appropriately immunized from 3% to 21%. Vaccine administration added fewer than 15 minutes to total appointment time and no adverse reactions occurred.

Conclusion: A bundle of quality improvement efforts utilizing lean six sigma methodologies increased the pneumococcal vaccination rate from 3% to 21% and reduced the time required for vaccination from 15 to 7 minutes. Elements of the bundle included: (1) clinician education, (2) posting of an easy-to-read version of the guidelines for vaccine administration, (3) simplification of workflow for administration of pneumococcal vaccines, and (4) integration and bundling of supplies necessary for vaccination. This bundle can be replicated at other sites using similar methodologies. The investigators intend on continuing through more iterations of these PDSA Cycles to achieve a goal of at least 70% appropriate pneumococcal vaccination among immunocompromised patients at the Iowa City VA Rheumatology Clinic.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/use-of-lean-six-sigma-methodologies-to-improve-pneumococcal-vaccination-rates-among-immunocompromised-veterans-with-rheumatologic-diseases-a-quality-improvement-project/