Identifying Strategies to Reduce Missed Opportunities for HPV Vaccination in Primary Care: A Qualitative Study of Positive Deviants

Abstract

The objectives of this study were to assess the contextual factors, practice strategies, and sustainability of interventions implemented during a national quality improvement (QI) project to raise human papillomavirus (HPV) vaccination rates. We conducted semistructured interviews with positive deviant practices that successfully reduced missed opportunities by ≥20% for HPV vaccination in the prior year. We assessed leadership support, motivators, interventions used, and sustainability. Key themes related to QI teams included strong leadership support, multidisciplinary teams, having a practice champion, and a collaborative environment. Themes related to the interventions included using a presumptive bundled recommendation for all appropriate vaccines at age 11, previsit planning, and reminders for preventive visits, which were sustainable for most practices 1-year postintervention. Both internal practice-level factors (multidisciplinary teams, collaboration, and previsit planning) and organizational factors (institutional support and health system–level reminders for preventive visits) were key to a successful QI intervention to improve HPV vaccination.

Identifying Factors that Support the Delivery of Exceptional Care in General Practice and Development of the IDEAL Framework: A Qualitative Study

“…Consistent with the literature, most practice-level factors constituted infrastructure, organisational structures, and processes used to deliver care (Goff et al, 2020;Rand et al, 2020). Strengthening these factors, referred to as the practice's core (Miller et al, 2010), can benefit the patient.…”

The use of positive deviance approach to improve health service delivery and quality of care: a scoping review

“…The scoping review findings have supported this statement and depicted that the selection process of PDs appeared to be too complex and dependent on the unique circumstances of each study or project. As a result, different articles and studies have utilized a range of methods and criteria to identify PDs including peer recommendations [ 25 , 49 , 52 , 106 , 120 , 123 ], and performance-based criteria such as lowest risk-adjusted morbidity [ 139 ], mortality [ 82 , 87 , 93 , 102 ], timely service [ 26 , 32 , 33 , 84 , 95 , 99 , 113 , 116 , 134 ], and standardized composite performance measures including high composite quality scores [ 86 , 115 , 137 ], high composite performance/healthcare service scores [ 11 , 23 , 27 , 43 – 45 , 53 , 62 , 65 , 69 , 75 , 78 , 109 , 110 , 117 , 118 , 122 , 124 , 131 , 138 , 140 , 144 ], and better clinical outcome scores [ 37 , 38 , 111 , 118 , 125 , 130 ]. This justifies the absence of a one-size-fits-all approach to selecting PDs, and the criteria used can vary greatly based on the specific domain and goals of initiatives.…”

“…This was seemingly intentionally done to mitigate the effect of time change on the performance level of health facilities and identify the hospitals that are truly positively deviant in comparison to those that are negatively deviant [ 85 ]. In addition, several of the included studies have used validated criteria to identify PDs that can support the above findings including lowest risk-adjusted morbidity [ 139 ], mortality [ 82 , 87 , 93 , 102 ], lowest age-adjusted mortality [ 136 ], and standardized composite performance measures including high composite quality score [ 86 , 115 , 137 ], and high composite performance/healthcare service scores as using row morbidity and mortality rates without confounder adjustment is a non-reliable indicator of high and low performance [ 11 , 23 , 27 , 43 – 45 , 53 , 62 , 65 , 69 , 75 , 78 , 109 , 110 , 117 , 118 , 122 , 124 , 131 , 138 , 140 , 144 , 157 ].…”

“…This challenge should be addressed via the use of robust qualitative methods that if done well could ensure both a broad sample of respondents (especially the front line) and employ saturation as a criterion for sample size and data collection iteration. This justification has been supported by the fact that several other studies have considered multiple settings and stakeholders including frontline staff in their studies signifying the importance of taking multiple participants from various settings and including different stakeholders if researchers are to get rich sources of information on the performance of health facilities and other responsible bodies within the health system [ 78 , 81 , 84 , 91 , 95 , 110 , 112 ].…”

Perspectives on Maternal Vaccination from Obstetrical Clinicians: A Qualitative Multi-site Study

“…Interview topics were specific to maternal influenza and Tdap vaccination including office policies and procedures, provider and nurse efforts to increase rates, previous quality improvement (QI) initiatives, perceived barriers and facilitators. Interview topics and discussion guides were based on our related studies (Rand et al, 2020 ) and other maternal vaccination studies (Ault et al, 2012 ; Mouzoon et al, 2010 ; Zakrzewski et al, 2014 ). The interview guide was piloted, and suggested prompts continued to be refined after piloting.…”