Examining Structural and Clinical Factors Associated with Implementation of Standing Orders for Adult Immunization

Background: Standing order protocols (SOPs) have been proven to increase vaccine uptake rates by providing nursing staff with the ability to administer vaccines without specified physician orders. We present findings from a formative qualitative study designed to examine the structural and clinical factors associated with implementation of SOPs and used the findings to inform a random national survey of physicians. 

Setting: Primary care practice-based settings, including community-based health clinics, academic-based health centers and health plan offices.    

Population: Physicians, nurses, a practice manager, a health plan medical director, medical assistants

Project Description: Eight in-depth interviews (n= 5 physicians, 1 nurse, 1 practice manager and 1 health plan medical director) and three interdisciplinary focus groups (n= 39, involving physicians, physician managers, nurses and other care-related support staff ) from both large and small practice settings with and without standing orders for immunization. Conversations were audiotape recorded, transcribed verbatim and analyzed using traditional consensus thematic analytic techniques.    

Results/Lessons Learned:  Findings provided in-depth insight into formal and informal practice-based policies and dynamics associated with developing and implementing SOPs for adult immunization. Responses varied by type of vaccine.  Specific barriers included patient level (e.g., immunization knowledge, fear of getting sick), provider level ( e.g., decision-making hierarchy, fear of malpractice), practice level (e.g., electronic medical records, culture) and system level (e.g., immunization policies).  For example, one physician noted that “They [physicians] see it as a threat to their position in the hierarchy. Physicians have always been the kings and they never really embraced team concepts. . . I think team concepts are very different strategy for physicians.” This formative study was used to help design a culturally relevant physician-based quantitative survey, which helped to identify various factors associated with the implementation of adult immunization standing orders protocols.