VFC Provider Site Visits

VFC Site Visit Training Video and Study Guide

VFC Video and study guide NEW May 2011

The compliance visits video and study guide were both developed as training tools for new VFC staff and for staff currently conducting VFC site visits. The video presents useful strategies that will enable staff members to become more effective and efficient during their site visits. Please use the study guide to facilitate discussion during group trainings and/or for individual trainings.

 

Overview

All immunization grantees are required to conduct site visits to VFC providers in both the public and private healthcare sectors. The purpose of the site visit is to review records of children who are immunized through the VFC program and to evaluate the provider's recordkeeping, vaccine handling and storage procedures and compliance with the requirements of the VFC program.

Persons conducting VFC provider site visits must complete all the questions in Section I of the VFC Site Visit Questionnaire. These are the required questions that must be asked to assess the provider's compliance with the VFC requirements. Questions identified with a red exclamation point (!) are considered high priority. Corrective actions must be developed if the provider is not in compliance with any of these questions. Section II of the questionnaire includes optional questions related to the Standards of Pediatric and Adolescent Immunization Practices. Section III of the questionnaire allows grantees to create custom questions specific to their programs (Section III is only available in the CoCASA software application).

The VFC site visit questionnaire is reviewed and updated annually and is available in the Comprehensive Clinic Assessment Software Application (CoCASA). Every awardee should develop a written protocol for provider site visits that outlines procedures for selecting provider sites for QA visits, conducting site visits—including instruction on how to administer the VFC Site Visit Questionnaire—and reporting results from completed site visits. All immunization grantees are required to conduct VFC provider site visits to enrolled VFC provider sites annually. Please refer to the annual grant guidance for specific information.

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VFC Site Visit Objectives

The main VFC site visit objectives are

• Reviewing of VFC eligibility screening procedures;
• Verifying the information in the provider profile;
• Administering the VFC Site Visit Questionnaire;
• Monitoring VFC vaccine administration, storage and handling;
• Ensuring VFC program policies are being properly implemented;
• Providing feedback and, as necessary, requesting corrective actions and follow-up of identified problems.

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The ABC's of Conducting Site Visits

Awardees must develop written policies on how to schedule, prepare, implement, and document both VFC and AFIX provider site visits. The policies should be as specific as possible. A good rule to follow is to provide enough detail in the policies so that a person with experience and the appropriate skills could conduct a site visit with minimal supervision or clarification of expectations. Awardees should have a flexible training plan to educate staff about why site visits are important and how to conduct site visits. The outline below can be used to assist grantees in developing procedures for separate VFC and AFIX site visits or, preferably, combined VFC/AFIX visits.

A. Training Staff and Required Equipment

In order to achieve the objectives, staff responsible for conducting VFC and AFIX site visits must be able to schedule, conduct and appropriately document the site visits (following the awardee-developed site visit protocol). Scheduling site visits includes notifying the provider of the time and date of the visit and what working space and materials the visitor will need.

Staff conducting the site visits must have received training on and must understand the following concepts:

• The purpose and importance of the visit;
• How to correctly administer the VFC Site Visit Questionnaire (if applicable);
• Objectives of the visit (preplanning);
• Communication skills required to effectively schedule, conduct, report feedback findings and document the content of the visit;
• Documentation required after completing site visit;
• Follow-up with provider.

B. Selecting Provider Sites

Awardees must develop a protocol for determining how VFC provider sites are selected for a visit. The following situations necessitate that a VFC site visit be conducted more frequently:

• High-volume vaccine usage
• Unusual ordering patterns
• Healthcare providers who are outliers with respect to vaccine ordering
• Reports of vaccine abuse or fraud
• Medicaid billing inconsistencies
• Unacceptable storage and handling practices

Additional provider sites should be visited according to a process of random selection. All staff should be made aware of the process used to select provider sites for QA visits and follow it accordingly. Awardees that conduct separate AFIX visits must develop protocols for determining how providers are selected for AFIX visits.

C. Scheduling Site Visits

A scheduling policy should include the following key points on how to schedule a site visit:

• Identify a contact person in the office to discuss site visit requirements;
• Arrange the date and time for the visit;
• Confirm contact name, job title and phone number;
• Confirm office address and location;
• Discuss with the office manager how much time you estimate the visit will take and whom you need to talk to during the visit;
• Request to have the following materials ready for your review on the day of the visit:
  • Charts (number and any criteria necessary to select charts)
  • VFC-related materials for VFC visits (such as VIS statements used, temperature logs)
• Send a confirmation letter or fax to contact with date, time, materials needed and summary of visit process;
• Confirm the visit with the provider 1 to 2 working days before the scheduled appointment.

D. Reviewing Previous Site Visit Information

Before making a site visit, staff should review all available information related to that provider site. Relevant documents to review may vary by awardee and type of visit but may include doses distributed and doses administered reports, enrollment data, provider profiles, past VFC site visit questionnaires and AFIX findings. A thorough review of these documents will help staff to be more aware of the past performance of the provider site as well as provide insight into questions that should be asked during the site visit. The provider profile should be carefully examined before every site visit; staff should be prepared to discuss necessary updates to the profile. In addition, staff should be prepared to review the VFC eligibility screening procedure with the provider.

Staff should also have on hand a selection of VFC-related forms and educational brochures available to distribute to provider site staff as needed.

E. Site Visit Questionnaire

Staff conducting VFC site visits are required to ask all questions in Section I of the VFC Site Visit Questionnaire developed by CDC. The questions contained in this questionnaire are essential to evaluating a provider's compliance with the requirements of the VFC program. All grantees must include CDC's required questions (Section I) as part of their VFC provider site visit data collection instruments. Some questions are designated as "high priority" and are identified by a red exclamation point (!). If answered inappropriately, the high-priority questions require a written corrective action. The inappropriate answer must be discussed with the provider and a corrective action agreed upon. Some inappropriate findings on the high-priority questions require that corrective actions be implemented immediately upon identification. Findings that place the viability of vaccine at risk, such as no working thermometers or no temperature log on the storage units, would need immediate attention.

Additional optional and custom questions can also be included in the VFC Site Visit Questionnaire at the discretion of the awardee. If the program decides to include optional and/or custom questions, these questions must be used consistently at all VFC site visits. Without consistent data collection, data cannot be used for meaningful analysis. All grantees are sent an electronic version of the VFC questionnaire in Microsoft Word annually before the start of the new calendar year.

Please Note: For programs using the CoCASA software, the VFC Site Visit Questionnaire is programmed into the software. Staff can enter responses to questions electronically and print out a copy of the completed questionnaire to share with the provider. Questions designated as "high-priority" are marked with a red exclamation point (!) icon. If noncompliant responses are given for any of these high-priority questions, the person entering the questionnaire will be required to enter a corrective action for each noncompliant response given. This function is programmed into the software to ensure that the areas of highest importance are being appropriately addressed. Staff members are not limited to entering corrective actions for these high-priority questions; they can enter recommendations for any issue identified during the site visit. Further information on how to use CoCASA and the current version of CoCASA can be found on the CDC CoCASA site.

F. Preparing for the Site Visit

The site visit policy should provide the staff with information on what equipment and resources to bring with them to the site visit. Some essential items to bring include:

• Laptop computer for staff that use CoCASA to enter VFC Site Visit Questionnaire responses
• Certified thermometer to check temperature of storage units (required for completion of VFC site visit questionnaire)
• Previous reports as applicable (i.e., previous VFC questionnaire results, provider profile or vaccine accountability reports)
• Blank forms as necessary (provider profile, VFC questionnaire)
• Handouts/resources, such as
  • Immunization brochures and other educational materials
  • Latest list of vaccines available through the VFC program
  • VFC Eligibility Screening Form
  • Standards for Pediatric Immunization Practice
  • Vaccine Information Statements (VIS) and instructions for their use (Make sure the VISs are current.)
  • Monthly temperature log for refrigerator and freezer recordings
  • Stickers for refrigerators/freezers/electrical outlets
  • VFC labels for labeling public vaccine
  • Refrigerator plug locks and signs
  • State Children's Health Insurance Program (SCHIP) information
  • Other information about upcoming CDC satellite courses, copies of any recent mailings from the awardee to providers about VFC or specific vaccine-preventable disease

G. Conducting the Site Visit

The main focus of the site visit will depend on the type of site visit being conducted. The VFC Site Visit Questionnaire guides the reviewer through a VFC provider site visit with the primary focus on adherence to VFC program requirements and correct vaccine storage and handling practices. The AFIX process requires the reviewer to identify strengths and opportunities for improvement related to administration of appropriate vaccines to eligible patients according to the recommended schedule. In a VFC/AFIX combined visit, the reviewer must focus on the entire immunization process from how the vaccine is handled and stored to ensuring that the appropriate vaccine is given to an eligible patient on schedule. Each awardee must provide written policies on how to conduct site visits, but these policies and procedures will vary depending on the type of site visit. Training staff on how to conduct site visits is an essential component of provider quality improvement activities. Certain interpersonal skills and behaviors can be helpful in making the site visit a success, and these skills should be emphasized:

• Be organized;
  • Know where to go, what time to arrive, and whom to talk to
  • Have identification and provide business cards
• Expect the unexpected and try to be flexible in addressing unexpected situations;
• Be a good observer and listener; use observations to back up findings of office's strengths and opportunities for improvement;
• Be an immunization resource and a partner to the provider and office staff.

H. Reviewing the Findings

Upon completion of the site visit, staff should discuss the outcomes in a face-to-face meeting with appropriate staff, either at the conclusion of the site visit or soon thereafter. This discussion should include a review of the visit findings and should address any recommended corrective actions for the provider site. A follow-up plan for addressing any issues of noncompliance or opportunities for improvement should be agreed upon between the immunization program staff and the provider site staff and should be documented in writing for the both office staff and immunization program. All details of the follow-up plan should be documented electronically. Please refer to the AFIX Standards (see Module 9-page 7) for specific content requirements regarding the AFIX feedback session.

I. Analysis of Provider Site Visits

In addition to sharing site visit results with the provider, the VFC/AFIX coordinator and/or immunization program manager should regularly review summary data from completed site visits. Reviewing summary data will help to track staff activities as well as identify any trends across multiple provider sites. Identified issues should be carefully reviewed with staff, and follow-up plans should be made to address staff and/or provider needs.

Please Note: Use of CoCASA will allow users to print out past VFC site visit results (at the provider level), which would be a valuable tool for identifying potential problems within that provider's office. Other reporting options are available through CoCASA and could be used to assist with the review of data at the program level.

Note: For more information about provider site visits including AFIX visits, please see module 9 of the VFC Operations Guide.

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