#MEQAPI – Tweetchat Oct 12-2017 3:00ET Vaccine Refusal

Just a reminder, MEQAPI stands for Monitoring & Evaluation, Quality Assurance, and Process Improvement, and you can visit us at http://www.meqapi.org.

Last week we chatted about how antibiotic resistance is a threat that just keeps giving, and how vaccines can help to reduce the impact. Yet vaccine adoption has its own problems. Two medical causes of non-adoption are allergies to vaccine components, and compromised immune systems. However, the biggest obstacle to adoption is that there is an influential and vociferous anti-vaccine movement that results in vaccine Hesitancy in the public. Vaccine Hesitancy can be further divided into two main categories:

  1. Vaccine Refusal: includes people who are susceptible, but who themselves refuse to take vaccines at the prescribed times, or deny vaccines as guardians to minors or others.
  2. Vaccine Delay: includes those who are open to being vaccinated themselves or for vaccination of their dependents, but who wait until some time after the recommended time of inoculation. This may involve wanting single vaccines instead of the combination versions such as the Measles, Mumps and Rubella (MMR), and the Diphtheria, Tetanus, and Pertussis vaccine (DTaP).

McKee and Bohannon list four categories for vaccine refusal or delay:

  • Religious reasons,
  • Personal beliefs or philosophical reasons,
  • Safety concerns, and
  • Desire for more information from healthcare providers.

The sizable (and increasing) number of hesitant people raises fears of increased outbreaks, especially of the pathogens with high basic reproduction number, such as Measles, Diphtheria, and Rubella.

The risks are not unknown to healthcare professionals, and some practices  have “fired” patients who refuse vaccines, on the grounds that these patients present a real and significant risk to other patients that they might encounter in waiting rooms.

The following pertinent articles have been provided by Physician’s Weekly:

We will take a QI approach, and discuss the topic using each of the typical arms of the basic Quality Improvement Ishikawa diagram to guide and support discussion. An Ishikawa diagram will be provided ahead of time and during the chat.

Vaccine Hesitancy

Participants will bring their own experiences, perspectives, and expectations to the discussion, but the topics might break down something along these lines:

    • Methods
      • Policies: office, organization, or national policies, including, etc
      • Workflow: how things are done including new patient onboarding, care provision, care coordination, ordering/prescribing, billing, patient transfer, etc.
      • Quality Improvement Policies
      • Subsidies and funding
      • Facility Policies
      • Specialty Policies
      • Employment policies
      • National and State Laws
      • Training
      • Navigable processes and policies
      • Vaccine refusal laws
    • Machines (incl equipment, EHR)
      • Personal Safety Equipment
      • Real Time Locator Systems (RTLS)
      • Med Equipment
      • Equip Ergonomics
      • Interoperability
      • EHR/Software
      • TeleHealth
      • Home Equipment
      • Access Control
      • Office Equipment
      • Product tracking
    • People
      • Staffing: sufficient and qualified staff
      • Patients – objectives, attitudes, ability to cope, beliefs, power-distance, health literacy
      • Subject Experts
      • Malpractice suits
      • Role Models, celebrity influence
      • Peer support/conflict
      • Training
      • Vendors
      • Friends/Family
      • Crime and safety
      • Attitudes/Bullying
    • Materials
      • Patients: as the “raw material” of the medical process. Patients may come with a range of attitudes, health problems, life situations, and ability to comply with treatment that are challenging and stressful.
      • Supplies: medical or office, inferior fax paper,
      • Data: ability to securely share with correct patient, specialist, lab, etc., and Access to Information
      • Patient self-care materials including checklists and how-to instructions, contact information for questions, and self-care consumables
      • Internet sources and access
      • Checklists, SoPs
      • Uniforms, footwear, personal protective equipment
      • Costed consumables
      • Combo vaccines
      • “Show me a needle” advertising
    • Measurement
      • Health outcomes
      • KPIs: operational metrics required by practice, local government, state, federal
      • Quality and safety metrics
      • Targets: set by practice, insurer, etc. as well as patient goals
      • Gini Index
      • Incentives and rewards
      • Adverse Eventss reporting
      • Effectiveness of measurement
      • Productivity Metrics
      • Patient Goals
      • R0, outbreaks, and spread
    • Environment
      • Noise: distracting noises, sound levels too high, etc. due to computer systems
      • Space: Cramped, uncomfortable work space etc.
      • Time: Too little time per patient or order, too little time in a day, too many demands
      • Location: things where they should be on the screen, click distance, and location of workstation relative to point of care and patient
      • Control: the degree to which the individual can control their workload and how to accomplish it
      • Fairness: the perception that the burdens and rewards, the effort and outcomes are spread amongst stakeholders in an equitable way
      • Temperature: too cold, too hot, too variable
      • Interruptions
      • Political climate
      • Social norms and group identity
      • Electrical Power
      • Climate and weather
      • Income inequality
      • Time
      • Direct marketing to patients

Some of the authors of the works cited above may be responding to the following topics, and participants are invited to describe their experiences of medication errors, and offer their insights and observations.


  1. What METHODS increase or reduce risks related to Vaccine Hesitancy
  2. What MACHINE factors increase or reduce risks related to Vaccine Hesitancy
  3. What PEOPLE issues increase or reduce risks related to Vaccine Hesitancy
  4. What MATERIALS increase or reduce risks related to Vaccine Hesitancy
  5. What MEASUREMENT factors increase or reduce risks related to Vaccine Hesitancy
  6. What ENVIRONMENTAL factors increase or reduce risks related to Vaccine Hesitancy


MEQAPI focuses on healthcare improvement, and in the spirit of shameless borrowing (and efficiency), takes existing perspectives from the IHI, AHRQ, and others.

To quote the IHI on what the Triple Aim encompasses:

The IHI Triple Aim is a framework developed by the Institute for Healthcare Improvement that describes an approach to optimizing health system performance. It is IHI’s belief that new designs must be developed to simultaneously pursue three dimensions, which we call the “Triple Aim”:

  • Improving the patient experience of care (including quality and satisfaction);
  • Improving the health of populations; and
  • Reducing the per capita cost of health care.

The six domains of care quality (STEEEP) mapped out by the Agency for Healthcare Research and Quality (AHRQ) are foundational to healthcare improvement. All care, and by inference quality measures, should be focused on being Safe, Timely, Effective, Efficient, Equitable, and Patient Centered.

The MEQAPI tweetchat aims to give voice to a broad range of stakeholders in healthcare improvement, and it embraces everyone from administrators to zoologists, and includes physicians, nurses, researchers, bed czars, cleaners, and yes, patients and care-givers.



Published by

Matthew Loxton

Healthcare Analyst using Lean Six Sigma, Knowledge Management, & Organizational Learning to improve healthcare http://linkedin.com/in/mloxton

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