Section V: Immunization

Transcription

1 Michigan Lcal Public Health Accreditatin Prgram Tl 2014 MPR Indicatr Guide Sectin V: Immunizatin MPR 1 The lcal health department shall ffer immunizatin services t the public fllwing a cmprehensive plan t assure full immunizatin f all citizens living in the jurisdictin. References: Omnibus Recnciliatin Act f 1993, sectin 1928 and Part IV- Immunizatins, Sec ; Current Vaccines fr Children (VFC) Operatins Guide; Current Immunizatin Prgram Operatins Manual (IPOM); PA 368 f 1978, MCL ; MCL (1); WIC Plicy Memrandum #2001; Current Cmprehensive Agreement (annual); Resurce Bk fr VFC Prviders (updated annually); Current Advisry Cmmittee n Immunizatin Practices (ACIP) General Recmmendatins n Immunizatin Indicatr 1.1 The LHD shall ffer vaccines t the public fr prtectin in case f an epidemic r threatened epidemic f a vaccine preventable disease. This indicatr may be met by: The LHD shws evidence f public health preparedness fr vaccine preventable diseases. Dcumentatin Required: Evidence that fllw up t a VPD has ccurred. Evaluatin Questin: Des the LHD have access t the CDC Manual fr Surveillance f Vaccine-Preventable Diseases and t the mst current MDCH Vaccine Preventable Disease Investigatin Guidelines? Indicatr 1.2 LHD cnducts free peridic immunizatin clinics fr thse residing in its jurisdictin. Clarificatin: free peridic immunizatin clinics refers t public vaccine, particularly VFC vaccine, VRP vaccine, and Sectin 317 funded vaccine. The LHD must be cnducting clinics and administering vaccines. This indicatr may be met by: The LHD ffers all vaccines recmmended by the Vaccines fr Children (VFC) Prgram t thse residing in its jurisdictin. The LHD is a VFC prvider. Dcumentatin Required: Dcumentatin f all walk-in and appintment based clinic hurs and lcatins shwing availability t meet the public demand. LHD VFC enrllment and prfile frms fr the past three years. Fr technical assistance, please cntact Christpher Smith at r smithc63@michigan.gv 1

2 Michigan Lcal Public Health Accreditatin Prgram Tl 2014 MPR Indicatr Guide Sectin V: Immunizatin Evaluatin Questins: Des the LHD prvide age apprpriate vaccine as recmmended by VFC? Hw des the LHD meet the public demand t vaccinate individuals? Hw are clinic hurs publicized? Are walk-in clients accepted? Are appintments able t be scheduled within a fur week time perid? Des the LHD ffer vaccines thrugh ther special MDCH publicly funded vaccine prgrams? Indicatr 1.3 The lcal health department uses the IAP mechanism t imprve jurisdictin and LHD immunizatin rates, assure cnvenient, accessible clinic hurs, crdinate immunizatin services, prvide educatinal and technical services, and develp private and public partnerships. This indicatr may be met by: The LHD submits semi-annual Immunizatin Actin Plan (IAP) reprts n r befre the due date each year. The LHD submits an annual IAP plan by the due date each year. At least ne representative frm each lcal health department will attend the IAP meetings held twice a year. Dcumentatin Required: IAP reprts submitted fr the last 3 years. IAP plans submitted fr the last 3 years. Evaluatin Questins: Did at least ne representative frm each lcal health department attend each f the bi-annual IAP meetings accrding t MDCH IAP Crdinatr Meeting sign-in sheets? Did the LHD submit all IAP reprts n time in the last 3 years? Did the LHD submit an annual IAP plan n time fr the last 3 years? Fr technical assistance, please cntact Christpher Smith at r smithc63@michigan.gv 2

3 Michigan Lcal Public Health Accreditatin Prgram Tl 2014 MPR Indicatr Guide Sectin V: Immunizatin Indicatr 1.4 The lcal health department shws evidence that the LHD recalls children nt up t date fr vaccines. This indicatr may be met by: The LHD cnducts reminder and/r recall (recall is required) effrts at least quarterly and details which methds were used (cards, letters, phne calls, ther methds f utreach). The LHD participates in cllabrative effrts with private prviders t prmte/implement a recall system. Dcumentatin Required: Dcumentatin f the number f reminder and/r recall ntices sent t LHD clients and details abut which methds were used (cards, letters, phne calls, ther methds f utreach). Review f three client recrds that have been tracked shwing respnse t recall. Dcumentatin f nging effrts t wrk with private prviders t prmte reminder/recall activities (e.g. educatinal, MCIR-related, r ther cllabrative effrts). Evaluatin Questins: Nne Fr technical assistance, please cntact Christpher Smith at r smithc63@michigan.gv 3

4 Michigan Lcal Public Health Accreditatin Prgram Tl 2014 MPR Indicatr Guide Sectin V: Immunizatin MPR 2 The lcal health department adheres t immunizatin plicies and prfessinal standards f practice as detailed in the Standards fr Child and Adlescent Immunizatin Practices and the Standards fr Adult Immunizatin Practices. References: Omnibus Recnciliatin Act f 1993, sectin 1928 and Part IV- Immunizatins, Sec ; The Natinal Vaccine Advisry Cmmittee (NVAC) The Standards fr Child and Adlescent Immunizatin Practices; Standards fr Adult Immunizatin Practices; Current Immunizatin Prgram Operatins Manual; Current AIM Prvider Tlkit (annual); Current Advisry Cmmittee n Immunizatin Practices (ACIP) General Recmmendatins n Immunizatin Indicatr 2.1 The LHD adheres t guidelines fund in the Standards fr Child and Adlescent Immunizatin Practices and Standards fr Adult Immunizatin Practices regarding vaccinatin plicies fr their wn clients. This indicatr may be met by: Barriers t vaccinatin shuld be identified and minimized at the lcal health department. Patient ut-f-pcket csts are minimized. Vaccinatins are crdinated with ther healthcare services being prvided at the health department. Clients seeking healthcare services at a lcal health department shuld be assessed at every encunter t determine which vaccines are indicated. Office r clinic-based patient recrd reviews and vaccinatin cverage assessments are perfrmed annually. Dcumentatin Required: Fee schedule. Methd f ntificatin used t let clients knw that immunizatin fees can be waived fr publicly purchased vaccines. Evaluatin Questins: D ther LHD prgrams, including thse that serve adlescents and adults, screen and refer clients t the immunizatin clinic r private prvider? Has the LHD addressed fcus effrts identified fr imprved immunizatin prcesses during the last AFIX review? Fr technical assistance, please cntact Christpher Smith at r smithc63@michigan.gv 4

5 Michigan Lcal Public Health Accreditatin Prgram Tl 2014 MPR Indicatr Guide Sectin V: Immunizatin Indicatr 2.2 The LHD adheres t guidelines fund in the Standards fr Child and Adlescent Immunizatin Practices and Standards fr Adult Immunizatin Practices when administering vaccines t clients. This indicatr may be met by: Written up-t-date vaccinatin prtcls are easily accessible at all lcatins where vaccines are administered. Lcal health department staff shuld simultaneusly administer as many indicated vaccine dses as pssible. Only true cntraindicatins shuld be used when vaccinating individuals. Prper cunseling f persns receiving vaccines shuld be perfrmed explaining immunizatin risks and benefits including the distributin f the Michigan VIS. All required fields fr vaccinatin must be prperly dcumented and recrds are easily accessible. Dcumentatin Required: One cmplete up t date Immunizatin Manual, signed annually by the LHD Medical Directr, available (standing rders and emergency treatment rders) at each immunizatin clinic site. LHD immunizatin screening tl. Current guide t cntraindicatins lcated at each clinic site (i.e., mst current CDC Guide t Cntraindicatins t Vaccinatins r AIM Prvider Tl Kit Guide t Cntraindicatins). LHD educatinal materials explaining immunizatin risks and benefits including VIS. Current immunizatin educatinal/prmtinal materials at each site. Evaluatin Questins: Are current ACIP recmmendatins published in the MMWR, ACIP/VFC reslutins, and guidelines t cntraindicatins fr pediatric and adult immunizatins included in the standing rders? Des a review f LHD client vaccine administratin recrds shw that there are n missed pprtunities t vaccinate? Des a review f LHD client vaccine administratin recrds at all clinics shw that all required immunizatin dcumentatin is crrect? Indicatr 2.3 The LHD adheres t guidelines fund in the Standards fr Child and Adlescent Immunizatin Practices and Standards fr Adult Immunizatin Practices regarding immunizatin plicies fr lcal health department staff. Fr technical assistance, please cntact Christpher Smith at r smithc63@michigan.gv 5

6 This indicatr may be met by: Michigan Lcal Public Health Accreditatin Prgram Tl 2014 MPR Indicatr Guide Sectin V: Immunizatin LHD ensures that immunizatin staff has been prperly trained and updated n immunizatin practices. Persnnel wh have cntact with patients are encuraged t be apprpriately vaccinated. Dcumentatin Required: Evidence f any staff training regarding current immunizatin practices/standards during the past three years and a list f CE/CNE s fr thse wh administer vaccine t ensure immunizatin staff has been prperly trained Evidence f any training regarding current immunizatin practices/updates during the past three years that the Medical Directr has received Public Health Nurse (PHN) immunizatin rientatin plan t assure immunizatin staff has been prperly trained Evidence f encuragement and/r prgrams t vaccinate LHD staff Evaluatin Questins: Nne Indicatr 2.4 The LHD adheres t guidelines fund in the Standards fr Child and Adlescent Immunizatin Practices and Standards fr Adult Immunizatin Practices by prmting immunizatins within their jurisdictin. This indicatr may be met by: Patient-riented and cmmunity-based appraches t increase immunizatin levels within the health jurisdictin (e.g. use f cmmunity data/demgraphics, client surveys, and freign language materials as apprpriate fr cmmunity, etc.) Dcumentatin Required: Evidence f patient-riented and cmmunity-based appraches (e.g. use f cmmunity data/demgraphics, client surveys, and freign language materials as apprpriate fr cmmunity, etc.) Plicies and/r written agreement with WIC clinics in the jurisdictin t prmte immunizatin f WIC clients, including dcumentatin that shws the LHD has encuraged the use f MCIR by WIC clinics WIC MCIR immunizatin cverage levels fr all WIC clinics within the LHD jurisdictin Evaluatin Questin: What effrts des the LHD undertake t prmte adlescent and adult immunizatins? Fr technical assistance, please cntact Christpher Smith at r smithc63@michigan.gv 6

7 Michigan Lcal Public Health Accreditatin Prgram Tl 2014 MPR Indicatr Guide Sectin V: Immunizatin MPR 3 The LHD shall cmply with federal requirements f the Vaccines fr Children (VFC) entitlement prgram. References: Current Immunizatin Prgram Operatins Manual (IPOM); Omnibus Recnciliatin Act f 1993, sectin 1928 and Part IV- Immunizatins, Sec ; Current Vaccines fr Children (VFC) Operatins Guide; CDC Manual fr the Surveillance f Vaccine-Preventable Diseases; Resurce Bk fr VFC Prviders MDCH (updated annually); ACIP/VFC Recmmendatins; Current Cmprehensive Agreement MDCH VFC/AFIX Site Visit Guidance Indicatr 3.1 The lcal health department shall assure adequate strage and handling f vaccines that it administers and distributes. (Immunizatin Prgram Operatins Manual, 2.1 AND Omnibus Recnciliatin Act f 1993) This indicatr may be met by: Annual enhanced VFC site visits at each LHD vaccine strage site with n utstanding issues. The lcal health department has apprpriate equipment and mnitring devices t safely stre vaccine at each f its clinic sites. The lcal health department can demnstrate that all staff respnsible fr strage and handling f vaccines are familiar with and have access t the mst current CDC strage and handling guidelines and ther guidelines, infrmatin and plicies related t strage and handling that are prvided by MDCH. The lcal health department has prcedures in place t assure apprpriate strage f vaccines and demnstrates these prcedures. The lcal health department uses apprpriate strage and handling methds in the rdering f vaccines and the transprt f vaccines t ff-site clinics and t ther prviders. Dcumentatin Required: Enhanced VFC site visit questinnaires, and enhanced VFC site visit crrective actin frms (if applicable), fr all LHD vaccine strage sites, which address the required dcumentatin listed belw: Up t date written plicies and prcedures fr the safe strage f vaccines, that are cnsistent with the mst recent CDC strage and handling guidelines, at each LHD clinic site where vaccine is stred and these plicies and prcedures readily available t all staff invlved in vaccine strage and handling. Written emergency prcedure within the Immunizatin Manual fr respnding t vaccine strage prblems that is up t date and easily accessible t all staff respnsible fr handling vaccines. The name and lcatin f an adequate back-up strage site and the written agreement updated annually stating that the site will serve as back-up fr vaccine strage. Fr technical assistance, please cntact Christpher Smith at r smithc63@michigan.gv 7

8 Michigan Lcal Public Health Accreditatin Prgram Tl 2014 MPR Indicatr Guide Sectin V: Immunizatin The past 90 days f temperature lgs, mnitred and recrded twice daily fr each f the units used t stre vaccine. Calibratin charts frm the last three mnths shwing weekly dcumentatin f the sensaphne/alarm temperature, and Dicksn pen (nt digital read-ut) r ther cntinuus temperature recrding device reading as cmpared t a certified thermmeter reading. Calibratin charts must als shw dcumentatin f any adjustments made t the sensaphne/alarm and/r Dicksn pen (r ther cntinuus graphing thermmeter device) during each weekly time perid t bring all devices within three degrees Fahrenheit f the certified thermmeter temperature. Written plicy within the Immunizatin Manual requiring the use f clers and apprpriate clant when transprting vaccine. Evaluatin Questins: D the enhanced VFC site visit questinnaires, and enhanced VFC site visit crrective actin frms (if applicable), shw cmpliance with the fllwing questins fr all LHD vaccine strage sites? Des the lcal health department have adequate equipment t stre frzen vaccine at all f its clinical sites where vaccine is rutinely administered? Des the lcal health department have adequate equipment t stre refrigerated vaccines at its wn facilities clinical sites? Are plug guards r ther mechanisms t prevent unwanted discnnectin frm the pwer supply present fr each refrigeratr and freezer used t stre vaccine and a DO NOT DISCONNECT warning which is visible at the utlet and circuit breaker used fr each unit? Des each refrigeratr/freezer have a certified thermmeter, recrding thermmeter, and, fr each unit used in the rutine strage f vaccines which exceed $1,000 in ttal value per unit, an alarm system in place and peratinal? Is a certified thermmeter lcated centrally in each vaccine strage unit/cmpartment? Des the lcal health department rutinely rder vaccine accrding t their Tiered Ordering Frequency (TOF) schedule? Des the lcal health department have the current CDC Vaccine Management Guide in view and at all vaccine strage sites? Des a visual inspectin f vaccine strage equipment and vaccines demnstrate that the lcal health department cmplies with CDC strage and handling guidelines? Des a check f sensaphne/alarm shw apprpriate settings fr the fllwing: current status/settings, sensaphne is plugged int a hard line analg phne line, pwer supply with battery backup and that the alarm system is peratinal? Des a check f the Dicksn graphing thermmeter (r ther cntinuus mnitring thermmeter) fr the past 90 days shw temperatures within range at all times, that charts have been changed weekly, pen Fr technical assistance, please cntact Christpher Smith at r smithc63@michigan.gv 8

9 Michigan Lcal Public Health Accreditatin Prgram Tl 2014 MPR Indicatr Guide Sectin V: Immunizatin tracing apprpriately with temperatures matching calibratin chart readings, and use f crrect charts fr each Dicksn mdel? Is the vaccine mnitring system functinal and a review f the settings f the system shws the ability t ntify persnnel in case f a vaccine management emergency? There are n accident reprts attributable t negligence n the part f the LHD filed, withut satisfactry reslutin f the prblem, fr any f its sites since its last accreditatin review. Are vaccines handled apprpriately in the clinic setting between main strage and administratin f the vaccine? Indicatr 3.2 The lcal health department shall assure that all requirements fr participatin in vaccine prgrams (including VFC and ther vaccine distributin prgrams) are met. Reference: Vaccines fr Children Operatins Guidelines, IPOM This indicatr may be met by: The lcal health department reviews and sends the Michigan Department f Cmmunity Health a VFC prvider enrllment frm and prfile frm fr the agency and fr each participating health care prvider, including each cmmunity/migrant/rural health center in its jurisdictin, n later than February 15 f each year. The lcal health department cmpletes the Michigan Department f Cmmunity Health vaccine dse reprting frms, temperature charts, and vaccine inventry frms and submits t MDCH as supprting dcumentatin with rders. The LHD prcesses prvider VFC vaccine rders in a timely manner and assures that rdering requirements are met fr each scheduled rder. The lcal health department adheres t ACIP recmmendatins published in the MMWR, ACIP/VFC reslutins, and guidelines t cntraindicatins fr pediatric, adlescent and adult immunizatins. The lcal health department maintains n file a sample f written infrmatinal material prvided t private prviders regarding requirements fr the VFC Prgram during the enrllment prcess. The lcal health department will perfrm VFC/AFIX site visits t VFC prviders in its jurisdictin, accrding t minimum and maximum standards frmulated by MDCH. The lcal health department dcuments and reprts t MDCH apprpriate fllw-up t Crrective Plans f Actin (CPAs) resulting frm VFC/AFIX site visits. The lcal health department assesses each client s eligibility fr the VFC Prgram and ther publicly funded vaccine prgrams. The LHD wrks with prviders t avid vaccine fraud, abuse and wastage. Fr technical assistance, please cntact Christpher Smith at r smithc63@michigan.gv 9

10 Michigan Lcal Public Health Accreditatin Prgram Tl 2014 MPR Indicatr Guide Sectin V: Immunizatin Dcumentatin Required: Dcumentatin f required number f VFC/AFIX site visits cmpleted fr the past 3 years with all CPAs addressed. Prir t 2013, LHD s will visit at least 20 VFC prvider sites each year and jurisdictins with 20 r fewer prviders shuld visit at least 80% f their sites each year. Beginning in 2013, LHDs will visit at least 50% f VFC prvider sites each year and the remaining 50% the fllwing year s that all sites receive a VFC site visit at least nce every tw years. The city f Detrit is expected t visit 100% f their prviders annually using Quality Assurance Specialists (QAS) as assigned t Detrit. Written prtcls r prcedures in the Immunizatin Manual used t assure each client s eligibility fr the VFC Prgram and ther publicly funded vaccine prgrams. Cpies f the VFC prvider enrllment frm and prvider prfile frm (paper r stred in MCIR) fr the agency and fr each participating health care prvider, including each cmmunity/migrant/rural health center, in its jurisdictin submitted by February 15th f each year fr the past three years. Prtcl within the Immunizatin Manual describing the prcess fr recruiting and enrlling new prviders int the VFC prgram. LHD billing shws that VFC eligible children are nt billed mre than the maximum amunt allwed fr the vaccine administratin fee by Centers fr Medicare & Medicaid Services CMS. LHD prtcl fr fllw-up n publicly purchased vaccine wastage and/r suspected fraud/abuse f publicly purchased vaccine. Evaluatin Questins: Des a review f LHD vaccine rders shw that the LHD has submitted and reviewed the supprting dcumentatin required with their wn vaccine rders? What prcess is in place at the LHD t assure that prvider vaccine rders submitted in MCIR are received and prcessed in a timely manner? Des a review f prvider vaccine rders shw that the LHD has reviewed the rder and required supprting dcumentatin submitted with the rder? Is the LHD prfile cnsistent with the amunt f vaccine rdered? Hw des the LHD target prviders fr VFC/AFIX site visits with ver 100 children, strage and handling issues r ther issues? Des the LHD cnduct the cmbined VFC/AFIX visit at site visits fr prviders wh have any children in the mnth age range? Can the LHD shw examples f effrts t educate prviders n vaccines, immunizatin guidelines and publicly purchased vaccine prgram guidelines? Are all vaccine lss reprts within the health jurisdictin reprted accrding t MDCH prcedures? Fr technical assistance, please cntact Christpher Smith at r smithc63@michigan.gv 10

11 Michigan Lcal Public Health Accreditatin Prgram Tl 2014 MPR Indicatr Guide Sectin V: Immunizatin MPR 4 The lcal health department shall be an active participant and user f the Michigan Care Imprvement Registry (MCIR). References: Michigan Administrative Cde, R (4.2); PA 368 f 1978; Current Cmprehensive Agreement; PA 540 f 1996; Michigan Administrative Cde, R , Michigan Administrative Cde, R (2b, 2d) Indicatr 4.1 The lcal health department shall sustain an immunizatin level fr their jurisdictin in the MCIR f at least 70% fr children wh are 19 thrugh 35 mnths f age fr fur (4) dses f DTaP vaccine; three (3) dses f pli vaccine; ne (1) dse f MMR vaccine; three (3) dses f Hib vaccine (r cmplete series); three (3) dses f hepatitis B vaccine; ne (1) dse f varicella vaccine (r dcumented immunity); and fur (4) dses f pneumcccal cnjugate vaccine (r cmplete series). This indicatr may be met by: A jurisdictin rate at r abve 70% fr the 4:3:1:3:3:1:4 vaccine series as shwn by MCIR cunty prfile reprt(s) created within 30 days f the accreditatin review. Dcumentatin Required: MCIR Prfile Reprt(s) shwing the number and percent f children wh have received fur (4) dses f DTaP vaccine; three (3) dses f pli vaccine; ne (1) dse f MMR vaccine; three (3) dses f Hib vaccine (r cmplete series); three (3) dses f hepatitis B vaccine; ne (1) dse f varicella vaccine (r dcumented immunity), and fur (4) dses f pneumcccal cnjugate vaccine (r cmplete series), (4:3:1:3:3:1:4 series) fr all cunties in the jurisdictin within 30 days f the accreditatin review. Written prtcl included in the Immunizatin Manual t maintain an immunizatin level f 70% r mre fr the 4:3:1:3:3:1:4 series in the MCIR fr children aged 19 thrugh 35 mnths which includes strategies t reach identified pcket f need areas. Evaluatin Questins: Has the lcal health department reached at least a seventy percent (70%) level fr children 19 thrugh 35 mnths f age within the lcal health department s jurisdictin as recrded in the MCIR fr the 4:3:1:3:3:1:4 series within 30 days f the accreditatin review? Indicatr 4.2 The lcal health department shall mnitr and evaluate adlescent immunizatin cverage levels fr children 156 mnths but nt yet 216 mnths ld in their jurisdictin in the MCIR fr ne (1) dse Td/Tdap plus the primary series; three (3) dses f pli vaccine; tw (2) dses f MMR vaccine; three (3) dses f hepatitis B vaccine; tw (2) dses f varicella vaccine (r dcumented immunity); and ne dse meningcccal cnjugate vaccine. The LHD will als mnitr and evaluate the adlescent immunizatin cverage in their jurisdictin fr three (3) dses f human papillmavirus (HPV) vaccine fr females 156 mnths but nt yet 216 mnths ld. Fr technical assistance, please cntact Christpher Smith at r smithc63@michigan.gv 11

12 This indicatr may be met by: Michigan Lcal Public Health Accreditatin Prgram Tl 2014 MPR Indicatr Guide Sectin V: Immunizatin The LHD runs and evaluates n a mnthly basis the MCIR adlescent immunizatin cverage level reprts fr children 156 mnths but nt yet 216 mnths ld in their jurisdictin in the MCIR fr ne (1) dse Td/Tdap plus the primary series; three (3) dses f pli vaccine; tw (2) dses f MMR vaccine; three (3) dses f hepatitis B vaccine; tw (2) dses f varicella vaccine (r dcumented immunity); and ne dse meningcccal cnjugate vaccine. The LHD runs and evaluates MCIR cverage level reprts fr three (3) dses f human papillmavirus (HPV) vaccine fr females 156 mnths but nt yet 216 mnths ld in the jurisdictin. Dcumentatin Required: MCIR adlescent cverage level reprts fr all cunties in the jurisdictin fr the three mnths prir t the review shwing cverage levels fr ne (1) dse Td/Tdap plus the primary series, three (3) dses f pli vaccine; tw (2) dses f MMR vaccine; three (3) dses f hepatitis B vaccine; tw (2) dse f varicella vaccine (r dcumented immunity) and ne dse meningcccal cnjugate (MCV4) vaccine. MCIR cverage level reprts fr all cunties in the jurisdictin fr the three mnths prir t the review shwing cverage levels fr three (3) dses f human papillmavirus (HPV) vaccine fr females 156 mnths but nt yet 216 mnths ld. Written prtcl included in the Immunizatin Manual t cnduct effrts t increase adlescent immunizatin cverage levels within the jurisdictin. Evaluatin Questin: What effrts has the LHD cnducted t target and increase adlescent immunizatin cverage levels in the jurisdictin? Indicatr 4.3 The lcal health department shall submit immunizatin data t the MCIR accrding t the statutry time lines. This indicatr may be met by: There is evidence that 80% f clients brn since 1994 receiving immunizatins at the lcal health department (all clinics in jurisdictin cmbined) have their immunizatin data submitted t the MCIR within 72 hurs. Reference: Administrative Rule , 5. Dcumentatin Required: MCIR Business Objects reprts fr all cunties within the jurisdictin fr 90 cnsecutive days prir t the review shwing 72 hur data submissin. Evaluatin Questin: Fr technical assistance, please cntact Christpher Smith at r smithc63@michigan.gv 12

13 Michigan Lcal Public Health Accreditatin Prgram Tl 2014 MPR Indicatr Guide Sectin V: Immunizatin Did 80% f the clients brn since 1994 receiving immunizatins at the lcal health department (all clinics in jurisdictin cmbined) have their immunizatin data submitted t the MCIR within 72 hurs f vaccine administratin? Fr technical assistance, please cntact Christpher Smith at r smithc63@michigan.gv 13

14 Michigan Lcal Public Health Accreditatin Prgram Tl 2014 MPR Indicatr Guide Sectin V: Immunizatin MPR 5 The lcal health department uses the cmbined MCIR and Schl Immunizatin Recrd-keeping System (SIRS) web-based prgram (MCIR/SIRS) t track immunizatin levels f childcare center enrllees and schl children. References: Current Cmprehensive Agreement; PA 368 f 1978, MCL , MCL , MCL , MCL , MCL , MCL ; PA 94 f 1979, MCL ; PA 451 f 1976, MCL Indicatr 5.1 The lcal health department uses the MCIR/SIRS reprting web-based prgram t assure cmplete and accurate data has been submitted fr schl entrants and sixth grade children by December 15 and March 15 f each schl year. This indicatr may be met by: The lcal health department will assure cmplete and accurate schl immunizatin data fr all schls in the jurisdictin have been reprted December 15 and March 15 f each year t MDCH. Dcumentatin Required: Written prcedures including MDCH Prtcls in additin t any health department prtcls that detail the methds fr reviewing schl immunizatin data. IP-100 Cunty status reprts fr each reprting perid fr the past three years. Dcumentatin shwing timely submissin f cmplete and accurate schl data by December 15 and March 15 f each year. Evidence f fllw up fr nn-cmpliant r delinquent schls which appear n the status reprt. Evaluatin Questins: Des the LHD update/maintain the schl facility master listing in MCIR/SIRS? What methds are used by the LHD t prmte that data submitted by schls is cmplete and accurate? Indicatr 5.2 The lcal health department will assure cmplete and accurate reprting f childcare center immunizatin data by February 1 st f each year t MDCH. Reference: PH cde Fr technical assistance, please cntact Christpher Smith at r smithc63@michigan.gv 14

15 This indicatr may be met by: Michigan Lcal Public Health Accreditatin Prgram Tl 2014 MPR Indicatr Guide Sectin V: Immunizatin The lcal health department will assure cmplete and accurate childcare immunizatin data has been reprted by February 1st f each year t MDCH. Dcumentatin Required: Written prcedures including MDCH Prtcls in additin t any health department prtcls which detail the methds fr reviewing childcare immunizatin data. IP-101 Cunty status reprts fr each reprting perid fr the past three years. Dcumentatin shwing timely submissin f cmplete and accurate childcare data by February 1 f each year. Evidence f fllw up fr nn-cmpliant r delinquent childcare centers which appear n the status reprts. Evaluatin Questins: Des the LHD update/maintain the childcare facility listing in MCIR/SIRS? What methds are used by LHD t prmte that data submitted by childcares is cmplete and accurate? Fr technical assistance, please cntact Christpher Smith at r smithc63@michigan.gv 15

16 Michigan Lcal Public Health Accreditatin Prgram Tl 2014 MPR Indicatr Guide Sectin V: Immunizatin MPR 6 The lcal health department cmplies with vaccine safety recmmendatins. References: Vaccine Adverse Event Reprting System (VAERS); The Natinal Childhd Vaccine Injury Act f 1986 (NCVIA); Federal Register 42 USC 300aa-25, 42 USC 300aa-26; Resurce Bk fr VFC Prviders MDCH (updated annually); Current Advisry Cmmittee n Immunizatin Practices (ACIP) General Recmmendatins n Immunizatin Indicatr 6.1 The lcal health department vaccine prgrams cnfrm t VAERS (Vaccine Adverse Event Reprting System) prgram requirements. This indicatr may be met by: The LHD maintains n file written VAERS plicies, prcedures, and reprts cmplying with prgram requirements. Dcumentatin Required: VAERS written plicy in the Immunizatin Manual which includes infrmatin n utilizatin f up t date reprting frms (available at the U.S. Department f Health & Human Services VAERS website) and the ability t submit VAERS reprts nline. Cpies f all VAERS reprts filed by the LHD in the last three years (either electrnically r n paper frms) shwing crrect dcumentatin n up t date frms. Evaluatin Questin: Nne Indicatr 6.2 The lcal health department prvides the apprpriate Vaccine Infrmatin Statements (VIS) t every client r parent/guardian prir t administering vaccines and educates all immunizatin prviders in the jurisdictin abut the use and surces f these statements. This indicatr may be met by: The LHD distributes VIS t all clients receiving vaccine listed n the Natinal Vaccine Injury Cmpensatin Prgram table at the clinic and dcuments the VIS date and date VIS given n the client s vaccine administratin recrd. There is a prtcl in place t assure that all prviders within the jurisdictin wh administer vaccines (bth VFC and nn-vfc prviders) are infrmed cncerning the requirements fr use f Vaccine Infrmatin Statements (VIS), and changes t VIS versins. Fr technical assistance, please cntact Christpher Smith at r smithc63@michigan.gv 16

17 Michigan Lcal Public Health Accreditatin Prgram Tl 2014 MPR Indicatr Guide Sectin V: Immunizatin The lcal health department maintains an apprpriate supply f VIS n site fr distributin t all immunizatin prviders. The lcal health department will prvide written ntice t individuals receiving a vaccinatin that the immunizatin data will be added t the registry. This is cmmnly dne using the Michigan versin f the Vaccine Infrmatin Statement (VIS) which includes the MCIR language. Dcumentatin Required: Up t date Michigan VIS versins fr all recmmended vaccines included n the Natinal Vaccine Injury Cmpensatin Prgram table are available fr distributin t clients and private prviders. Prtcl which describes the plan fr VIS educatin and distributin t all immunizatin prviders (bth VFC and nn-vfc) wh administer vaccines within the jurisdictin. Evaluatin Questin: Des the LHD use the versin f the VIS that cntains the MCIR statement infrming an individual f their right t pt ut f the MCIR? Indicatr 6.3 The lcal health department has a referral system if prblems arise after a client receives vaccine. This indicatr may be met by: The LHD prvides instructins fr patients receiving vaccines cncerning pssible reactins and fllw-up care. Dcumentatin Required: Example(s) f patient infrmatin handuts given t each patient, listing pssible reactins t vaccines, which include phne numbers t cntact if questins arise. Evaluatin Questins: Nne Fr technical assistance, please cntact Christpher Smith at r smithc63@michigan.gv 17