Carrots and Sticks: Achieving High Healthcare Personnel Influenza Vaccination Rates without a Mandate

OBJECTIVE. Achieving high healthcare personnel (HCP) influenza vaccination rates has typically required mandating vaccination, which is often challenging to implement. Our objective was to achieve >90% employee influenza vaccination without a mandate. DESIGN. Prospective quality improvement initiative setting and participants. All employees of a 2-hospital, 1,100-bed, community-based academic healthcare system. METHODS. The multimodal HCP vaccination campaign consisted of a mandatory declination policy, mask-wearing for non-vaccinated HCP, highly visible "I'm vaccinated" hanging badges, improved vaccination tracking, weekly compliance reports to managers and vice presidents, disciplinary measures for noncompliant HCP, vaccination stations at facility entrances, and inclusion of a target employee vaccination rate (> 75%) metric in the annual employee bonus program. The campaign was implemented in the 2011-2012 influenza season and continued throughout the 2012-2013 through 2014-2015 influenza seasons. Employee compliance, vaccination, exemption and declination rates were calculated and compared with those of the seasons prior to the intervention. RESULTS. Compared with vaccination rates of 57%-72% in the 3 years preceding the intervention, employee influenza vaccination increased to 92% in year 1 and 93% in years 2-4 (P<.001). The proportion of employees declaring medical/religious exemptions or declining vaccination decreased during the 4 years of the program (respectively, 1.2% to 0.5%, P<.001; 4.4% to 3.8%, P=.001). CONCLUSIONS. An integrated multimodal approach incorporating peer pressure, accountability, and financial incentives was associated with increased employee vaccination rate from <= 72% to <= 92%, which has been sustained for 4 influenza seasons. Such programs may provide a model for behavioral change within healthcare organizations.