A qualitative analysis of the impact of healthcare personnel influenza vaccination requirements in California

Highlights

• We evaluated CA law requiring hospitals to offer employees flu vaccination.

• Participants thought the law was not strict enough to impact vaccination rates.

• Hospitals thought the law helped raise vaccination awareness and change culture.

• The law prompted hospitals to improve data systems for monitoring vaccinations.

• In some hospitals and counties, CA law stimulated adoption of stricter requirements.

Abstract

Objective

Using qualitative methods, we explored the implementation of California's 2007 influenza immunization requirements of hospital-based health care personnel (HCP).

Methods

We conducted nine case studies of California hospitals with different HCP vaccination rates and policies. Case studies consisted of interviewing 13 hospital representatives and analyzing relevant hospital documents, including influenza policies. We also conducted 13 semi-structured phone interviews with key state and county public health officials, union representatives, and officials of various professional healthcare organizations.

Results

Our qualitative results suggest that California's vaccination requirements likely did not increase influenza vaccination uptake among HCP. The law was not strong enough to compel hospitals with low and medium vaccination rates to improve their vaccination efforts, and hospitals with high vaccination rates were able to comply fully with the law by continuing to do what they were already doing – namely offering vaccinations to HCP, providing education about the risks of influenza and the benefits of vaccination, and obtaining signed declinations from those who refuse vaccination. Nonetheless, we found that by publicly raising the issue of influenza vaccination in the context of public safety and healthcare quality, California's law encouraged hospitals to develop and implement data systems to monitor the effectiveness of vaccination promotion efforts and prompted discussions, and, in some cases, adoption of stricter vaccination requirements at hospital or county levels.

Conclusions

Our findings generally support the literature that suggests that permissive influenza vaccination requirements, though politically feasible, provide little direct incentive for hospitals to focus efforts on increasing HCP vaccination rates.

Introduction

To protect patients and maintain treatment capacity during influenza outbreaks, the CDC's Advisory Committee on Immunization Practices recommends voluntary influenza vaccination of health care personnel (HCP) [1], [2], [3]. However, typically less than half of all HCP receive annual vaccinations [4], [5]. The perceived ineffectiveness of voluntary programs has led numerous professional societies to call for implementing HCP vaccination requirements coupled with penalties for non-compliance [6], [7], [8]. Starting 2013, CMS required that general acute care hospitals (GACHs) participating in its quality reporting program report uptake annually for personnel working in the facility [9]. Case studies and testimonials suggest that the few hospitals requiring influenza vaccination as a condition of employment have generated vaccination coverage above 90% [10], [11]. Yet, proven strategies for translating this success beyond a small number of hospitals have yet to emerge.

State requirements are an alternative to hospital-initiated requirements [12], [13]. As of fall 2012, ten states have enacted such laws that apply to GACHs [14]. At least eight states require GACHs to provide influenza vaccination to HCP, and, in four states, GACHs must do so free of charge to HCP; seven require hospitals to maintain records about their HCP vaccination status; and five require vaccination data be submitted to appropriate state and local health authorities [14]. Most states, however, have permissive laws that do not impose strict penalties for non-vaccination on workers or the facilities that employ them. Rhode Island is the only state that has stricter requirements because it specifies penalties for non-compliance. Besides requiring unvaccinated HCP with direct patient contact to wear a surgical mask during periods of declared widespread influenza, Rhode Island law subjects HCP who fail to wear a mask and facilities that fail to enforce this rule to a $100 penalty and disciplinary action [14]. While politically feasible, whether and how permissive state requirements influence facility-level policies remain uncertain.

To improve understanding in this area, we conducted an evaluation of California's state HCP influenza vaccination requirement. Enacted in 2007, California law stipulates that all GACHs must annually offer employees free onsite influenza vaccination and educate them regarding risks of influenza and benefits of vaccination; require employees to be vaccinated or sign a written declination; and report vaccination and declination rates to the California Department of Public Health (CDPH). In 2008, CDPH clarified hospitals’ obligation to provide vaccination education to non-employees and the method by which hospitals should calculate and report vaccination/declination rates [17]. While California law is consistent with CDC recommendations [1], it is permissive because it does not stipulate enforcement mechanisms or penalties for non-compliance. California is an ideal setting for evaluating the impact of permissive vaccination requirements because it is a large state (>400 GACHs) and its law contains many provisions enacted in other states [14], [18].