Performance Improvement 1997. Georgia State Clinic Assessments of Immunization Coverage: Impact of Management and Clinic Immunization Practices



Between 1986 and 1994, the State of Georgia implemented a program of audits of the immunization practices of all State public health immunization clinics (227 in 1994) in an effort to improve child immunization rates. During this time period, the immunization rate for preschoolers increased from 31 percent to 90 percent. This evaluation found that the performance of these audits was significantly associated with higher immunization rates for preschool children in the clinic catchment areas.

Other management and medical practices were found to be significantly associated with increased immunization rates. Greater accessibility, informed vaccine administration practices (such as following only true contraindications), adequate clinic resources, and staff participation in leadership were also associated with higher immunization rates. The report lists 11 recommendations associated with the findings; in particular, the audits of the clinics should continue, and efforts to improve immunization rates should be comprehensive in scope and continuous in application. Findings from the evaluation of this highly successful program formed the basis of Centers for Disease Control and Prevention (CDC) recommendations to all States.


The purpose of this study was to evaluate how audits conducted by the State of Georgia affected immunization rates among the preschool population, to assess management and organization factors associated with immunization coverage, to identify aspects of immunization clinic practice and organizational or managerial processes associated with changes in immunization coverage levels, and to make recommendations regarding the implementation of similar programs in other projects in the United States.


The Public Health Service (PHS) objectives for the year 2000 include 90 percent immunization coverage levels for children up to the age of 24 months. The diseases against which immunization is sought are diphtheria, tetanus, pertussis, poliomyelitis, measles, mumps, rubella, Hemophilus influenza type B, and hepatitis B. The CDC's Comprehensive Childhood Immunization Initiative was developed to address this objective through an intensified strategy that includes service delivery, assessment, information and education, operational research, and surveillance.

To improve its child immunization rates, the State of Georgia conducted a program of annual audits between 1986 and 1994. The program allowed and encouraged district and clinic immunization staff at the State's public health clinics to implement interventions to increase clinic-specific coverage levels. Various approaches and combinations of interventions to change clinic practices were undertaken and evaluated.


Data for the study were drawn from clinic audit data, 1987-94, and from a self-administered mail survey of key immunization personnel in all public health clinics in the State of Georgia (227 in 1994). Individuals surveyed included district health directors or program managers, district immunization coordinators, and clinic immunization coordinators or clinic lead nurses. The survey response rate, due to intensive follow-up procedures, was 100 percent. Univariate and multivariate methods were used for analyses relating information on clinic practices from the surveys to information on audit rates from medical files.


The study found substantial improvement in coverage rates following the audit program, with median immunization rates at the clinics improving from 31 percent to 90 percent. Staff participation in the audit process resulted in their increased awareness of the performance levels of their offices, and of how their clinic compared with state averages; this, in turn, appeared to prompt improved immunization rates at the clinics.

Accessibility factorsþsuch as short waiting times, fixed fees, and convenient hours of serviceþwere associated with higher immunization rates at the clinics. Clinics with higher immunization rates also used improved vaccine administration practices, suggesting an association between appropriate clinical knowledge by key staff and higher coverage rates. Early outreach, aggressive reminder and recall, and close coordination with Women, Infants, and Children (WIC) and other programs were also associated with higher immunization rates.

Clinics with adequate resources had higher coverage rates. Computer technology, appropriately supported and implemented, appeared to benefit clinic rates. Lower coverage rates were more likely to be found at sites in the process of computerization than in those that were fully automated, although clinics without computers had even lower immunization rates. These findings suggest the importance of support and training to the process of computerization, as well as the importance of computerization in the clinic setting.

The study also found that staff participation and management leadership were associated with higher immunization rates. The investigators conclude that sustained efforts to improve immunization rates can make a difference.

Use of Results

Eleven recommendations based on study findings are included in the report, supporting continuing efforts to improve immunization rates through strategies that are long term, comprehensive in scope, and continuous in application. The report recommends continuing the audits, which were a critical element helping to improve these rates, and furnishing audit results to clinic providers and managers. Recommendations also target ready accessibility to clinics, early outreach, and aggressive reminder and recall. Staff training and development were encouraged to provide accurate information about contraindications and to minimize missed opportunities for immunization. Clear management practices that support and recognize the importance of immunization, that foster staff participation in decisions about improving immunization rates, and that provide adequate staff and financial resources were also recommended. The report recognizes the important role that programs such as WIC can play in improving immunization rates, and it calls for ongoing study of the role of computerization and of improvement efforts in other settings as they relate to coverage rates.

These recommendations have had far-reaching application, providing a national model for immunization practice. Georgia staff report that the evaluation findings have stimulated new staff thinking about immunization practice, as well as changes in policies to carry out the study's recommendations. Georgia's successful strategyþusing routine assessment and feedback to achieve high sustainable coverageþwas adopted and produced successful results in public health clinics in Colorado, Illinois, Iowa, Kansas, and South Carolina. It also worked in private and managed care provider settings in Arizona, Massachusetts, New York, and Washington.

Several reports of early study findings have appeared in the Morbidity and Mortality Weekly Report and CDC information sheets. Workshops and presentations on the project have been conducted throughout the term of the project, resulting in replication of this approach in other States. Furthermore, CDC reports that the recommendations of this study now provide the basis for their national immunization program: Since 1995, all States and localities receiving Federal funds for vaccine programs have been required to conduct annual assessments of vaccine rates in public health clinics.

Agency sponsor:

National Immunization Program

Federal contact:

Andrew Baughman
PIC ID: 5354

Performer organization:

Battelle Centers for Public Health Research and Evaluation, Arlington, VA