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Video Tutorials for School Immunization Reporting

State: OR Type: Promising Practice Year: 2017

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Multnomah County Health Department
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Video Tutorials for School Immunization Reporting
Brief description of LHD Multnomah County is an urban and suburban community located in the northwest corner of Oregon and is home to the state's largest and fourth largest cities (Portland and Gresham respectively.) Despite being the smallest in square miles, Multnomah County is the state's most populous (766,135 residents, 19.5% of Oregon's population) and diverse county, with a population that is 11.1% Latino, 6.9% Asian, 5.3% Black/African American, 3.7% multiracial, 0.8% Native American, 0.6% Pacific Islander (together totaling 24.5% of Oregon's persons of color), and 71.7% non-Latino White. Public health issue Oregon School Law determines school immunization requirements and aims to reduce vaccine preventable disease among children and the greater community. In order to keep kids in school and ensure a safe learning environment, the law requires vaccination for eleven preventable diseases for children attending public and private schools, preschools, childcare facilities, and Head Starts. Oregon also allows parents to take a non-medical exemption in place of vaccination. Since the early 2000's, the non-medical exemption rates in Oregon steadily rose where Oregon and Multnomah County rates peaked in 2014 at 7.0% and 9.6% respectively. Anecdotal evidence suggests that school and facility staff feel overwhelmed by the reporting process. Staff are unequipped to follow best practice immunization record keeping and reporting. With budget cuts in public health communicable disease programs and flat State funding to carry out this reporting requirement, an online, on-demand solution to training staff was imperative. In this way, staff are better trained to more accurately assess immunization records. Good data and record keeping is essential to keeping kids in school. Goals and objectives of proposed practice 1. Demonstrate partnership with local schools and childcare facilities a. Enable staff to become empowered reporters b. Enable staff to take ownership and have buy-in to the reporting process 2. Provide school and facility partners with training options for the school immunization process a. Provide on-demand training videos b. Empower reporters with job aids and resources to produce/submit accurate reports c. Encourage good record keeping for outbreak preparedness How was practice implemented/activities As reporting requirements became more complex in the past 10 years, the Multnomah County Health Department (MCHD) Immunization Program received repeated requests for more training on the reporting process. These requests came more frequently during the height of the reporting season when school and facility staff realized they did not know how to complete their reports and Immunization Program staff had the least amount of time to spend on one-on-one training. Many school staff were unable to attend trainings during health department hours of operation and wanted training in an electronic format so they could easily access it online when they had time. In response to the many requests received from school/facility staff, Immunization Program staff undertook the task of developing eight instructional videos at the beginning of the 2014-2015 school year. Created in the Powtoons software program, these videos answered the need for an asynchronous training option. Results/ Outcomes Eight step-by-step videos were created ranging in length from 3 to 9 minutes each. The videos were posted on the MCHD Immunization website, accessible by all school/facility staff. During the 2015-16 school year, each video was viewed an average of 74 times. That represents just under 17% of the facilities/schools on our roster; however, more than expected. A survey taken at the end of the school year suggests that of the respondents who used the videos, 81% found them to be useful. Based on many years of experience, the Immunization Program staff noticed that reports submitted were more complete, accurate, and on time. Public Health impact In schools/facilities with higher exemption rates, it is all the more critical to have accurate records of immunization and non-medical exemptions on hand. Accurate records help school and public health staff to identify those who may be at risk of a vaccine preventable exposure or outbreak. Public health's goal is to maintain a healthy learning environment that keeps as many kids as possible in school. The immunization review process is very detailed and can be challenging for many child care providers and school staff who do not have prior experience with immunizations and/or immunization record review. Some challenges of reviewing immunization records include: Identification of incomplete records Understanding of dosing schedules (school requirements vs clinical recommendations) Determination of invalid doses Understanding of non-medical exemption process. Translation of foreign records Missing or duplicate records Lack of awareness/use of available tools, including the State online immunization registry Website web.multco.us/school/immunization-report-instructions
Statement of the problem/public health issue Despite the Oregon Health Authority requiring a robust immunization reporting process, it has been historically underfunded and has not developed online trainings that would benefit child care facilities and schools statewide. Moreover, because of high staff turnover at schools/facilities and the 9-10 month gap between reporting periods, the Immunization Program staff spend many hours each winter re-teaching the process to school/facility staff, both in groups and on a one-on-one basis. Most schools and facilities do not have an electronic reporting system to track their students so manual reporting is required. School and facility staff serve as gatekeepers and are responsible for enforcing State immunization requirements, yet they are often lacking in knowledge on how to complete the reporting process. The immunization review process is very detailed and can be challenging for child care providers and school staff who do not have prior experience with immunizations and/or immunization record review. Tracking, assessing, and reporting immunization data for each student is also a time consuming process and often gets put off due to the immediate needs of childcare and teaching demands. Similarly, many of the childcare facilities are small businesses with very limited staff and other resources. The burden of finding time to complete the immunization process becomes a bothersome inconvenience and one that some facility staff resent. Additionally, due to their hectic schedules, many school and facility staff who are delegated responsibility for school immunization reporting, are unable to leave the facility to attend a two-hour, in person workshop. For all the reasons above, school/facility staff are poorly motivated to put much effort into submitting accurate reports. When this happens, immunization records are incorrectly assessed by school staff so children may receive exclusion orders (excluding them from school on the third Wednesday of February) which they may not need. Due to an extremely tight budget, limited Immunization Program staff and the lack of a statewide electronic reporting system, MCHD relies on the accurate reporting of school/facility staff because of their full access to student immunization records. The inability of school staff to assess records accurately puts an added burden on already tight Immunization Program staffing to review and correct mistakes when/if found. Program staff review all records submitted but depending on time and extremely compressed deadlines, may not be able to catch all incorrect (or missing reports), thereby putting children at risk for unnecessary exclusion from their school or childcare setting. Target population affected by problem The MCHD Immunization Program works with approximately443 childcare facilities, preschools, kindergartens, alternative and private schools that report on over 30,000 children. The majority of schools and facilities are English speaking. A small percentage of these are owner-operated childcare businesses that are Russian, Vietnamese, Somali and Spanish speaking. What has been done in the past to address the problem? In the past and in the absence of statewide standardized training opportunities on how to complete the school immunization reporting process, the Immunization Program conducted a series of three to four classroom-based workshops each November and December. During the course of the reporting season (each January and February), staff also ended up working one-on-one with at least 30% of facility/school staff to complete their reports. As the number of reporting schools and facilities continued to grow each year, having only classroom-based workshops became unsustainable and was not enough to meet the training needs of the ever-growing list of staff who needed assistance. It became apparent and imperative to develop additional training strategies and modalities to educate the school/facility staff when it was convenient for them. Why the current/proposed practice is better? Providing education and training on how to do the immunization reporting process in advance of the actual reporting season is crucial. The instructional videos, posted on the MCHD Immunization Program website, are accessible by any school/facility staff member 24 hours a day, 7 days a week. Although the Immunization Program continues to offer in-class training opportunities in the fall of each year, many school/facility staff cannot spare the time to leave their facilities for a two hour comprehensive workshop. Many others feel confident about some parts of the reporting process, but need the opportunity to learn or review only certain parts of the process. Now having online, on-demand training videos allow school and facility staff to obtain training 24/7, whenever their schedule allows. During the 2015-16 school year (the first full year that the videos were available) each video was viewed an average of 74 times. That represents just under 17% of the facilities/schools on our roster. A survey taken at the end of last school year suggests that of the respondents who used the videos, 81% found them to be useful or extremely useful. Based on many years of experience, the immunization program noticed that reports submitted were more complete, accurate, and on time. Moreover, while still having to spend time on the phone helping schools/facilities with their reports, the questions and time spent was reduced when helping those staff who had viewed the videos. Is current practice innovative? How so/explain? This is an innovative practice for the State of Oregon. As Oregon's largest county, Multnomah County leads the way in providing alternate training resources and job aids. By adopting existing technology (Powtoons) the Immunization Program staff developed a viable training program for school immunization reporting. The State of Oregon does not provide local health departments with a standardized training curriculum or guidelines. The innovation began with breaking the entire reporting workflow into six logical steps. Each step provides the reporter with a timeline for each step, the tools or resources to complete each step, and the reporting instructions. The eight videos that were developed followed the six steps including an introductory video and an additional tutorial. Is current practice evidence based? If yes, provide references. Our anecdotal findings over many years informed us that: facility/school staff could not attend classes due to the time commitment and location of workshops many facilities are owner-operated and do not have employee back-up facility/school staff often do their reporting after work hours so are unable to get one-on-one assistance many reports were submitted incomplete, inaccurate and/or late requiring Immunization program staff to contact the facility to get the necessary information. Does practice address any CDC Winnable Battles? This practice supports the goal of Achieving a global reduction of deaths resulting from measles and rubella.” (Winnable Battles, Global Immunizations)
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Goal(s) and objectives of practice 1. Demonstrate partnership with local schools and childcare facilities a. Enable staff to become empowered reporters In the 443 children's facilities and private/alternative school in Multnomah County, the vast majority of staff tasked with assessing immunization records are non-medical professionals with very demanding jobs. These reporters include individuals for whom English is their second language and individuals with varying levels of education. The Immunization Program must provide job aids and self-paced training to enable school staff of all backgrounds to complete this important work in a timely manner. b. Enable staff to take ownership and have buy-in to the reporting process Reporters have expressed feeling burdened by the immunization reporting process in the past, and initially, immunization reporting may seem beyond their scope. To engage school staff in immunization review and reporting, the Immunization Program emphasizes accurate immunization record-keeping as important to the well-being of students. MCHD believes reporters are doing crucial work by reaching out to parents to gather updated immunization records and providing accurate reporting. School staff have access to parents, students, and immunization records that the Health Department lacks. Recognizing the important role that school staff play in accurate immunization record review and reporting, the Immunization Program wants to provide useful trainings that honor the many commitments of our partners. With successful assessment and reporting outcomes, the Immunization Program hopes to instill a sense of ownership and pride by facilities of their own immunization/non-medical exemption rates. 2. Provide school and facility partners with training options for the school immunization process a. Provide on-demand training videos Multnomah County's budget cannot sustain a system that requires personalized assistance by phone to >30% of its facilities throughout the reporting season. Written materials repeatedly proved insufficient guiding resources and with the number of facilities increasing yearly, Multnomah County was unable to meet in-person training needs on the flexible schedule required by those in education and child care. Reporters need asynchronous access to reporting instructions 24/7. On-demand videos allowed school staff to complete the reporting process on weekends, from home, or over holiday breaks, common strategies to meet the first January deadline without the responsibility of vigilant childcare in the workplace. The goal of the video project is to reach 10% of the reporting schools and facilities. This goal would satisfy the Immunization Program's training surge capacity during the immunization review process, the Program's busy season.” b. Empower reporters with job aids and resources to produce/submit accurate reports Due to recent legislative imperatives and public concern, it is crucial that Immunization Program staff further support their reporters to provide the most accurate immunization and exemption information possible. To maintain and develop positive partnerships between the Health Department and local schools, Multnomah County needed to respond to increased reporting demands with increased support. The intersection of the Immunization Program and all school staff is the resolute mission to keep kids healthy, safe and in school. Supporting school staff in accurately reviewing and reporting on immunization records is a way to provide our school partners with the public health tools necessary to accomplish our shared mission. c. Encourage good record keeping for outbreak preparedness MCHD needs to be able to maintain herd immunity in order to protect children by creating a safe and healthy learning environment and to keep them in school. What did you do to achieve the goals and objectives? The Six Steps” concept, previously used in written instructional materials and in-person trainings, was used to structure the video series. A script was written with content for each video based on the six step concept. This approach was designed to offer reporters a bite size” approach thereby simplifying the reporting process. Effort was made to look for a program that included graphics and visuals that would give the videos a welcoming look and were relatively enjoyable as well as educational. Staff in MCHD programs that had experience in producing similar videos were consulted to determine which software would best fit the needs of the project. After this research, the Powtoons software was selected based on its ease with which to work, engaging animation capabilities and low subscription rate. The easy-to use video software allowed for internal design and publication, keeping the Immunization Program within budget. Its visual nature answered the needs of learners with varied learning styles and language barriers. The videos include an introduction to the reporting process, immunization record review examples, and demonstration of how to tally individuals and facility-wide immunization statistics, and instructions for completing the corresponding reports. Beyond providing instructions in an appealing manner, the videos show mock immunization records and provide specific examples of how to identify missing, invalid, or incomplete vaccines. Screenshots of actual immunization reporting forms were included so viewers could see examples while directly referencing their own identical forms. The videos present key deadlines for the next five years, to minimize the need for updates and maintenance. After development of each script, the visual content was produced. The accompanying audio was then recorded and integrated at appropriate video segments. Once published, the videos were posted on YouTube and linked to the Immunization Program website. Reporters were encouraged to use the videos by way of written materials sent to them by mail and various other communication methods (e.g. phone, e-mail.) Any criteria for who was selected to receive the practice (if applicable)? Not applicable. The immunization reporting tutorial videos are available on the Multnomah County Community Immunization Program website. Timeframe for the practice The entire project spanned from March 2014 to September 2015. However, actual development of the videos was very compressed given pre-set State school immunization reporting deadlines 3/2014 – The scripts for each video were written. 10/2014 – Meetings with MCHD Communications Program staff were held to gather information and obtain advice on the best type of software program to use with the ability to make improvements/ revisions and/or to develop subsequent videos over time. 12/2014 – The first five videos were completed, published and posted to the Immunization Program website. These were completed in time to meet the needs for the first reporting deadline (second Wednesday of January.) 2/2015 – The next two videos were completed, published and posted to the Immunization Program website. These were completed just in time to meet the needs for the second reporting deadline (end of February.) 9/2015 – Due to new State requirements enacted in August 2015, the previous videos were updated and another new video was completed and published. Involvement of other stakeholders and roles in planning/implementation Internally, the Immunization Program collaborated with the Multnomah County Communications Program to discuss various software options within our time and funding constraints. The Communications Team also provided technical feedback on the pace and visual design of the videos to improve the user training experience. The instructional videos were revised according to both technical and content feedback obtained from the MCHD Communications Program. Externally, we recognized the need to further develop a relationship with the school and facility community that would more readily empower them to use the tools and videos available in reporting the accurate immunization status of the kids. This in turn would also create more trust and confidence among parents, knowing that their children are enrolled in a facility that encourages and provides a safe learning environment. Recognizing that the immunization reporting requirements were often perceived as burdensome and even beyond the scope of school and facility staff, the Immunization Program sought to provide increased support that would accommodate the scheduling priorities of school and facility staff. Due to conflicting priorities, it was often difficult to get in touch with the school or facility staff who were responsible for reporting. Having resources available at any time helps to provide the support that staff need in order to complete their reports. Further, these flexible training resources demonstrate understanding of the competing priorities of school staff, and honor their efforts to provide high quality reports. This was our first of several steps to build a more virtual presence for our community stakeholders. Since building these videos we have also developed a series of webinars and set up an ImmiProgram e-mail in order to send out regular email communications. Our videos remain a popular tool with the schools/facilities. Our intention and hope was that by creating additional, accessible resources for staff to use at their convenience, we would see an increase in the quality and accuracy of reporting. As discussed in the next section, we found that there were fewer incomplete reports requiring follow-up and there were fewer late reports requiring follow-up. Based on this, we felt more assured that schools and facilities had increased accuracy of the immunization status of the children in their care thereby keeping kids in school and in a safe and healthy learning environment. Start-up and in-kind costs; funding services associated with practice? Provide breakdown. Estimated costs include the following: Staffing (Program Technician): Wrote script and recorded audio 15 hrs x $20.12/hr = $302 Powtoons Subscription: $120 Total: $422 * Staffing (CDC Public Health Associate): Designed and developed videos 0.5 FTE x $41.000 (excluding benefits) x 10 mos = $17,082. As a Public Health Associate, her salary was paid by CDC.
Goal(s) and objectives of practice 1. Demonstrate partnership with local schools and childcare facilities a. Enable staff to become empowered reporters In the 443 children's facilities and private/alternative school in Multnomah County, the vast majority of staff tasked with assessing immunization records are non-medical professionals with very demanding jobs. These reporters include individuals for whom English is their second language and individuals with varying levels of education. The Immunization Program must provide job aids and self-paced training to enable school staff of all backgrounds to complete this important work in a timely manner. b. Enable staff to take ownership and have buy-in to the reporting process Reporters have expressed feeling burdened by the immunization reporting process in the past, and initially, immunization reporting may seem beyond their scope. To engage school staff in immunization review and reporting, the Immunization Program emphasizes accurate immunization record-keeping as important to the well-being of students. MCHD believes reporters are doing crucial work by reaching out to parents to gather updated immunization records and providing accurate reporting. School staff have access to parents, students, and immunization records that the Health Department lacks. Recognizing the important role that school staff play in accurate immunization record review and reporting, the Immunization Program wants to provide useful trainings that honor the many commitments of our partners. With successful assessment and reporting outcomes, the Immunization Program hopes to instill a sense of ownership and pride by facilities of their own immunization/non-medical exemption rates. 2. Provide school and facility partners with training options for the school immunization process a. Provide on-demand training videos Multnomah County's budget cannot sustain a system that requires personalized assistance by phone to >30% of its facilities throughout the reporting season. Written materials repeatedly proved insufficient guiding resources and with the number of facilities increasing yearly, Multnomah County was unable to meet in-person training needs on the flexible schedule required by those in education and child care. Reporters need asynchronous access to reporting instructions 24/7. On-demand videos allowed school staff to complete the reporting process on weekends, from home, or over holiday breaks, common strategies to meet the first January deadline without the responsibility of vigilant childcare in the workplace. The goal of the video project is to reach 10% of the reporting schools and facilities. This goal would satisfy the Immunization Program's training surge capacity during the immunization review process, the Program's busy season.” b. Empower reporters with job aids and resources to produce/submit accurate reports Due to recent legislative imperatives and public concern, it is crucial that Immunization Program staff further support their reporters to provide the most accurate immunization and exemption information possible. To maintain and develop positive partnerships between the Health Department and local schools, Multnomah County needed to respond to increased reporting demands with increased support. The intersection of the Immunization Program and all school staff is the resolute mission to keep kids healthy, safe and in school. Supporting school staff in accurately reviewing and reporting on immunization records is a way to provide our school partners with the public health tools necessary to accomplish our shared mission. c. Encourage good record keeping for outbreak preparedness MCHD needs to be able to maintain herd immunity in order to protect children by creating a safe and healthy learning environment and to keep them in school. Did you evaluate your practice? The goals we set out for this project were mostly qualitative. We were attempting to build a partnership with our schools and childcare facilities. We used this video series as an opportunity to reach out to a portion of our community in order to achieve that. Due to the staggered release of the videos, the first quantitative measure was taken during the 2015-16 school year. The average number of views for each video was 74. This represents just under 17% of the 443 schools on our roster that year. Given that we anticipated reaching 10% of the total community, our goal was exceeded. Videos Views Introduction 64 Step 1, Collect Information about your Students 65 Step 2, Assess Student Immunization Records 114 Step 3, Fill Out the Primary Review Summary 83 Step 4, Send the First Report 61 Step 5, Fill Out Section D and Cancel Exclusion Orders 65 Step 6: Complete and Send Pages 3 and 4 of the Primary Review Summary 62 Tally Tutorial 75 At the end of the 2014-15 school year, a survey was sent to all the schools and childcare facilities. With 72 respondents, 50% of which used the videos during that school year, 81% agreed or strongly agreed that the instructional videos were useful to them. Question: I found the instructional videos (located on Multnomah County Immunization webpage) to be useful. Strongly Disagree-1.39% (1) Disagree2.78% (2) Undecided5.56% (4) Agree20.83% (15) Strongly Agree19.44% (14) Did Not Use50.00% (36) Total - 72 In addition to these quantitative measures, the Multnomah County Immunization Program evaluated the reports received during that school year and found that the quality and accuracy of the reports was generally higher; there were fewer incomplete reports requiring follow-up; and there were fewer late reports requiring followup. Overall, the efforts to empower the reporters to produce better reports is positively impacting the program.
Lessons learned in relation to practice Videos were developed and published in sequence of corresponding steps of process. These staggered release dates matched the 2015 due dates for each step, allowing us to publish videos in a timely manner, while taking time to refine videos for the final steps of the process. Future dates of deadlines were factored in to minimize future updates It was possible to develop a quality product at minimal cost of the software It was possible to develop a quality product in a compressed, minimal timeframe Lessons learned in relation to partner collaboration (if applicable) Partners/stakeholders expressed appreciation to have the opportunity to watch the training videos at their convenience. Did you do a cost/benefit analysis? If so, describe. No. Stakeholder commitment to sustain practice? The Immunization Program maintains and updates the videos as needed according to changes in Oregon School Law and feedback from school reporters. The videos are a more sustainable practice than in-person trainings because these materials can be referenced at any time for training new school/facility staff or as a refresher for others who are more familiar with the process With the passage of a new school immunization law requirement (SB 895) in August, 2015, Oregon schools are now required to publically post their facility's immunization coverage and non-medical exemption rates twice a year (September and April) and in three different ways (on their website, in a newsletter and physically posted in a main office.) In this way, parents are able to easily find the status of their child's school/facility and compare it to the immunization and non-medical exemption status of children in all Multnomah County schools and facilities. Under this expansion of school immunization law, school and facility staff receive more public and parental inquiries about their immunization data. For this reason, we expect increased demand for training, a gap that the immunization videos are in place to fill. With the addition of public posting on their own websites, school and facility staff may be more vested in the immunization review process. We hope that providing engaging and accessible training materials will support school administrators in understanding the immunization review process and developing a sense of ownership of their facilities immunization coverage and exemption numbers.
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