Doing it right: Samaritan Healthcare dramatically improves its PPV rate

How did a 50-bed, rural hospital in Moses Lake, WA go from having a 2.9% pneumococcal polysaccharide vaccine (PPV) rate in Q4 of 2004 to a 79% rate in Q4 2006?

“By firmly believing that the staff wants to do it the right way,” says Gwen Cox, Director, Quality Improvement at Samaritan Healthcare. This is the premise she has worked under since she was hired in August of 2006.

Samaritan Hospital is the only hospital in Grant County. It serves approximately 80,000 people and it is known for its advanced facilities for trauma and deliveries. Yet, the low PPV rate affected their quality of care.

Gwen dove into the job by making a detailed assessment of current efforts. She looked at the data, learned where patients came from, identified informal leaders, and spent time with the utilization coordinators. She looked at staff education and realized it was not where it should be. She noted that physician education had no standardization and had variations in practice as a result.

She emphasized that it was important to dig deep and learn the culture of the organization in order to know how to motivate staff and to really understand what’s going on behind the data. Armed with the assessment—and with support from senior leadership—she formed a team including front line staff, the pharmacy, a physician sponsor, an administrative sponsor, and a facilitator.

The team researched other hospitals’ standardized order sets and took the best methods and tools to customize for use in their own facility. Qualis Health provided support via tools, educational teleconferences, and on-site visits. The team then developed a standardized physician order set.

The next step was to educate the staff about the new standardized order set. The PPV education campaign included one-on-one education with staff, posters, e-mail messages, presentations at staff meetings and endorsement by the CEO at internal meetings.

Gwen emphasized however, that the “One-on-one education was by far the biggest factor for success.”

Also very important, according to Gwen, was her participation in the daily point-of-care reviews. The daily reviews allowed immediate intervention and education.

While the implementation of a standardized order set has yielded great results, there have been many challenges along the way. The biggest hurdle was the limitation of Samaritan’s EMR system. Their system wasn’t easy to use and with the new standardized order sets, there were concerns that they would have to duplicate documentation. They finally had a special screen built into the EMR system to meet their needs.

Resistance from staff was another challenge. Gwen spent time finding out what was driving the resistance. She sums it up with three points:

• Discomfort with changing a way of practice
• Fear of getting it wrong
• Giving in to "the man!"

She appealed to their pride with the “broken window theory:”

You regularly drive past a house and one day you see a broken window. A week later it’s still not fixed. A month later it’s still not fixed and people are starting to throw trash in the yard. Soon it becomes a dumping ground because it’s become a place that people don’t respect.

As Gwen put it, “We needed to show our pride or DOH will come in, CMS will come in, and patients will complain.”

While Samaritan has made tremendous improvement, Gwen says they won’t stop until their PPV rate is 100%. They are constantly tweaking their standardized order sets to improve the process and they continue to educate staff.

Doing things the right way had a residual effect as well. Gwen notes that since Samaritan began their PPV effort, quality improvement has spread to other areas of the hospital too!