JCAHO adds flu standard with no declination statements required
Declinations seen as obstacle to flu immunization
Hospitals must try to improve participation in influenza immunization of health care workers, but the Joint Commission on Accreditation of Healthcare Organizations won't require them to collect declination statements from employees who refuse the vaccine.
The new Joint Commission standard, which goes into effect Jan. 1, 2007, requires hospitals to evaluate why some employees do not receive the annual vaccine and to take steps to improve participation. (For the Elements of Performance, see box below.)
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The standard follows recommendations by the Centers for Disease Control and Prevention (CDC) for hospitals to boost influenza immunization. The CDC has advised hospitals to ask employees to sign declination statements if they refuse the vaccine as a strategy to track vaccinations and improve compliance.
"At a minimum, there has to be access to the vaccine on-site and there has to be an education program telling people why it's important," says Robert Wise, MD, vice president of JCAHO's division of standards and survey methods. "You have to evaluate the actual rate [of immunization] and the reasons for nonparticipation."
Influenza immunization of health care workers has come to the forefront as a patient safety issue. Nationally, only about 40% of health care workers receive the vaccine, according to CDC surveys.
"A fragile patient should not have to risk being exposed to a potentially deadly infection from a health care worker," Wise says.
Declinations: A burden with no benefit?
From nurses' unions to infection control experts, everyone agrees that health care workers should receive influenza immunization to prevent hospital-based spread of the disease. The specter of pandemic influenza just magnifies the importance of vaccination.
But how should hospitals ensure that employees receive the vaccine each fall? There are a variety of strategies, but none has been as contentious nationally as the use of declination statements.
The Joint Commission received more comments on that potential aspect of the standard than any other issue, says Wise. Infection control organizations such as the Association for Professionals in Infection Control and Epidemiology and the Society for Healthcare Epidemiology of America endorsed the use of declination statements.
The American College of Occupational and Environmental Medicine argued that declination statements would divert resources that could be used for more positive methods to improve compliance.
The new standard gives hospitals flexibility to find other ways to address nonparticipation, says William Buchta, MD, MPH, medical director of the Employee Occupational Health Service at the Mayo Clinic in Rochester, MN.
"Hospitals could use declination forms, but the evaluation also could be accomplished by other means," Buchta says. For example, hospitals could study trends, conduct voluntary sampling surveys of those who did not get the vaccine, or ask employees for comments about why they did not get vaccinated, he says.
Declination statements would place a burden on employee health departments that are already stretched, says MaryAnn Gruden, MSN, CRNP, NP-C, COHN-S/CM, past executive president of the Association for Occupational Health Professionals in Healthcare, which also provided comments to JCAHO.
"It really would pull the limited resources that we have in our offices to tracking that [immunization] process rather than trying to educate employees and trying to come up with innovative ways to get more employees vaccinated," says Gruden, who is employee health coordinator at Western Pennsylvania Hospital in Pittsburgh. "We really wanted to focus on those positive efforts rather than a paper trail of declinations."
JCAHO provided the following comment in its rationale for the standard:
"One obstacle to effective vaccination is declination by health care personnel. Health care personnel may decline vaccination for many reasons. They may have been vaccinated elsewhere, have a medical contraindication, or have other personal reasons for declining the vaccine. Vaccination might also be declined because it is offered at inconvenient times or locations. Whatever the reason, it is important for organizations to identify why individuals do not participate in the vaccination program, work to overcome these reasons, and increase vaccination rates."
Who should you vaccinate?
The Joint Commission also addressed other concerns in its final standard. As initially proposed, the standard would have applied to "staff, students, volunteers, and licensed independent practitioners." The final standard simply requires hospitals to immunize "at least staff and licensed independent practitioners."
"There are large hospitals where a student may happen to come in with a physician and be there for a day or two. Were we really expecting the organization to offer it to [every] student or volunteer? It was so important for this to be successful that we did not want to create burdens that really may not add much to the overall safety," says Wise.
The Joint Commission also will not require hospitals to cover the cost of vaccination, although the CDC recommends that the vaccine be offered free of charge. No other JCAHO standard addresses the issue of cost, notes Wise.
"There is a requirement that the organization make it accessible," he says. "You would have to have it on three shifts during the flu season." An evaluation might indicate cost as a barrier to vaccination and then the hospital might choose to reduce the cost to employees or make it free of charge, he says.
With the standard in place and a renewed emphasis on influenza vaccination of health care workers, Wise says immunization rates should rise. "Health care workers, when coaxed a little, will do the right thing," he says.
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