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 Table of Contents  
Year : 2021  |  Volume : 5  |  Issue : 4  |  Page : 138-143

Using a quality improvement project to enhance the standard vaccination rate for long-term patients in mental health services in Qatar

1 Department of Pharmacy, Mental Health Services, Hamad Medical Corporation, Doha, Qatar
2 Medical Department, Mental Health Services, Hamad Medical Corporation, Doha, Qatar

Date of Submission31-Jul-2021
Date of Acceptance27-Sep-2021
Date of Web Publication30-Nov-2021

Correspondence Address:
Dr. Nervana Elbakary
Hamad Medical Corporation, P.O. 30381, Doha
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/hm.hm_47_21

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Background: Countries launch vaccination programs to ensure vaccination coverage as part of the global health security. Special populations including patients with severe mental illness are under average vaccination rate. We aimed to improve the percentage of long-term patients in Qatar's mental health services who received their routine vaccination by the end of 2020 from a baseline rate of 10% to 90% from all vaccination types needed. Methods: This was an interrupted time series quality improvement project using two structured Plan-Do-Study-Act cycles to test the success of the outcome and process measures to reach the desired aim. Run charts were utilized to display the monthly vaccination rates as an outcome measure and the rate of vaccination refusals by the patients as a process measure. A multidisciplinary team was assembled. Root cause analysis was performed. Prioritizations for certain types of vaccines to be given were done. Results: We identified 50 eligible patients. Throughout 12 months, we reached a final vaccination rate of 92%. Number need to treat was used to express the effect size and was calculated as 1.2. Refusals to vaccinations by patients dropped from 41% at the start of the project to only 4% by the end. Conclusion: High vaccination rates over a 12-month period can serve as an indication for the success of the intervention. Sustainability of the results can be achieved by multiple strategies. These results may be useful to hospitals considering vaccine implementation or those currently struggling with implementation barriers.

Keywords: COVID-19, flu vaccine, hepatitis vaccine, pneumococcal vaccine, psychiatry, quality improvement

How to cite this article:
Elbakary N, Riaz S, Mahran I, Assar AH, Abdallah O, Abukuhail R, AlKhuzaei N, Eltorki Y. Using a quality improvement project to enhance the standard vaccination rate for long-term patients in mental health services in Qatar. Heart Mind 2021;5:138-43

How to cite this URL:
Elbakary N, Riaz S, Mahran I, Assar AH, Abdallah O, Abukuhail R, AlKhuzaei N, Eltorki Y. Using a quality improvement project to enhance the standard vaccination rate for long-term patients in mental health services in Qatar. Heart Mind [serial online] 2021 [cited 2022 Sep 28];5:138-43. Available from: http://www.heartmindjournal.org/text.asp?2021/5/4/138/331564

  Introduction Top

Introducing a vaccine into the body to produce an immunity to a specific disease is called vaccination.[1],[2] As per the Centers for Disease Control and Prevention (CDC), since 2010, flu-related deaths have reached up to 56,000; moreover, around 320,000 patients are being infected with pneumococcal disease yearly, which causes over 5000 deaths. Chickenpox, diphtheria, flu, hepatitis A and B, human papilloma virus, measles, meningococcal disease, mumps, pneumococcal disease, rubella, shingles, tetanus pertussis, and other serious illness can be prevented by vaccines.[3] Countries launch vaccination programs to ensure full vaccination coverage as part of the global health security worldwide.[4],[5]

There are some special groups who are below an acceptable vaccination limit, including patients with severe mental illness. This could be due to lack of awareness of vaccines benefits, the inability of the health-care system to vaccinate all population, low socioeconomic status, or misconceptions about the safety and efficacy of vaccines.[6],[7],[8]

Druss et al. reviewed 113,505 veterans with chronic conditions and found that those with dual diagnosis (combined psychiatric and substance use disorders) compared with people with either condition alone had lower rates of getting preventive care including immunization practice. The findings of this study might be limited by the cohort of the patients as it did not include inpatient long-term patients.[9] Miles et al. stated that the physical health of people with severe mental illness is complex and compromised due to several reasons, including the side effects of psychotropics, mainly metabolic syndrome, the poor lifestyle, drug dependence or addiction, and being homeless.[10] All or some of these factors make the rate of vaccination for psychiatric patients falls behind the standard level.

For instance, in a western state of USA where the population exceeded 500,000, Miles et al. surveyed 392 psychiatric patients with severe mental illnesses and they found that only 47.4%, 36.2% and 5.4% of them received their influenza vaccine, pneumococcal vaccine, and hepatitis B vaccine, respectively.[10] In a different geographical area, the influenza vaccination rates among adults with mental illness were lower than the rate in the general population of Ontario, Canada (6.7% vs. 31.1%, respectively).[11] These studies reflect that there is a need for attention to such group of vulnerable patients. The fact that most of the studies took place in US and Canada indicates the need to perform similar studies in different populations around the globe.

In mental health services (MHS) in Qatar, the baseline data showed that only 10% of chronic and long-term psychiatric patients had received their required adult vaccination, either as per the age group or as categorized by their risk factors, and the vaccination rate in MHS falls short of what is expected under the Qatar national health strategy 2018–2022.[12]

Given these findings and the known effectiveness of vaccination, the quality improvement (QI) team sought to create and develop a patient-centered, staff-friendly intervention to increase the vaccination rates.

Specific aim

The project's aim was to improve the percentage of long-term psychiatric patients who received their routine vaccination by the end of the year 2020 to reach an average of 90% compliance rate with all composite vaccination types (flu, pneumococcal, hepatitis, shingles, or herpes zoster vaccines) at the psychiatric hospital in Qatar.

  Methods Top


MHS is the central tertiary psychiatric facility of Hamad Medical Corporation (HMC) Hospitals in Qatar, servicing a referral base of most psychiatric patients in Qatar. The hospital medical record is being operated using Cerner® electronic health record (EHR). Long-term patients were defined as any patient who had a continued stay for 6 months or more in the facility without a planned discharge. Some of the long-term patients lived in residential compounds while others lived in the inpatient wards with the acute patients. MHS depends on a central corporate medication store for the supply of the required medications. All types of vaccines were available throughout the year. Formulary restrictions were found for only one type of the vaccines used. All patients included in this study are covered by a national medical insurance, so that all patients are exempted from paying to have any medication.

Study design and analysis

We performed an interrupted time series study using structured QI methodology and two types of Plan-Do-Study-Act (PDSA) to test the success of the process measures. Run charts were used to display the monthly vaccination rates and the rate of vaccines' refusals by the patients monthly. In program evaluation studies, like ours, with <50 participants, the results of significance tests could be misleading because they are subject to Type II errors. In these situations, effect size (ES) expressed as number need to treat (NNT) should be estimated and reported to strengthen the link between research and practice in an intuitive and practically meaningful way. Cook and Sackett and Laupacis et al. advocated to the use NNT in behavior change interventions.[13],[14] NNT thus simply in this context could be defined as the number of people who need to be exposed to the interventions by the vaccination team to reach the desired behavior change (accepting vaccination) in one more individual relative to a control conditions (as usual care without the team's interventions).

This report was prepared in concordance with the revised Standards for QI Reporting Excellence guidelines and Standards for Reporting Implementation Studies checklist [StaRi checklist, Supplementary file].[15],[16]

Baseline data

Despite the availability of most routine vaccines in MHS pharmacy, no integrated vaccination campaign had been previously attempted in MHS before. Overall, 10% of all the chronic patients in MHS have received their routine adult vaccinations.

Improvement team

A multidisciplinary team consisted of a psychiatrist, clinical pharmacists, an infection control specialist, a clinical nurse specialist and a QI specialist.

Improvement diagnostics

[Appendix 1 - Figure 1] A root cause analysis (RCA) or a fishbone diagram determined the unforeseen causes of the low percentage of adult vaccination in MHS. RCA diagram has classified the problem into four main themes: (i) people, which then categorized into (a) patients' unawareness about the importance of vaccination and (b) physicians' noncompliance with the international and local vaccination guidelines, (ii) policy, as adult vaccination was not part of any policy in MHS concerning the physical health of long-term patients, (iii) process, as there was inadequate training for nurses about administrating and monitoring adverse effects postvaccinations, last, (iv) LOGISTICS, as there was limited access to some vaccines due to formulary restrictions and absence of automatic reminders from the system to alert doctors about the due vaccines.

Planned vaccines

Based on the CDC recommendations about adult vaccinations either by age grouping or by medical conditions grouping, a clinical needs assessment was done for all patients then the team decided to prioritize the required vaccines to be given for the patients as follow:

  1. Flu vaccine in the fall seasons (from September to March)
  2. Pneumococcal polysaccharide vaccine (PPSV23) for all patients 65 years old or more that had no record of that vaccine before or had a record for it 5 years or more before the initiative. Pneumococcal vaccine 13 will be given for the only immunocompromised patient first, then after 8 weeks will be given PPSV23
  3. Hepatitis vaccine for all diabetic patients in intervals of 0, 1 month, and 6 months
  4. Recombinant varicella zoster vaccine for patients 50 years old or more.

Improvement interventions

The team reviewed the literature to conceptualize the drivers to be used when implementing changes [Appendix 1 - Figure 2]. Under “people” domain, to improve the physician awareness and compliance with the vaccination guidelines, the clinical pharmacists worked to educate and remind doctors in the weekly rounds about the clinical importance of adult vaccinations and the indications, contraindications for each vaccine in addition to other useful strategies. Working with patients and their families, the team customized educational sessions to discuss the vaccines with the patients that adopted the ABCs: A = Attitudes toward vaccination, B = Barriers to vaccination, C = Completed vaccination series. The team distributed leaflets and flyers in the units taken from the corporate infection control office to reinforce the idea of vaccines' benefits and to enhance awareness about the importance of routine vaccination. The leaflets were made available at the nursing stations in all units.

Under “process” domain, the team developed a structured targeted education for nurses about the difference between vaccines' types, vaccine administration and monitoring of postvaccination adverse effects. Under “logistics” domain, communication with the main store about the need to have a consistent vaccine supply was done by the pharmacists. Additionally, we coordinated with the technical team of the hospital to activate the periodic reminders of the due vaccines in the patients' charts as a clinical decision support system (CDSS). Under the domain of “policy,” we disseminated the project with its findings to the hospital management to develop actions for the current and future long-term patients in order to sustain the improvement.


Outcome measure

The percentage of long-term psychiatric patients who received their routine adult vaccination monthly.

Process measures

  1. Number of clinical pharmacy interventions done by pharmacists that were linked to their work with the physicians about adult vaccination
  2. The number of total vaccine doses dispensed from pharmacy each month
  3. Educational sessions/handouts given to the patients/families about vaccination. The team decided to determine the effectiveness of that education by measuring the total number of refusals to vaccinations which reflects the change in the patients' attitude and beliefs toward vaccines.

Balancing measure

Vaccine adverse events: The number of allergic or anaphylactic reactions secondary to vaccination.

Evolution of the interventions over time

Physician awareness

The PDSA conceptualized the methodology of stating low and go rapid. The intervention team decided to run multiple types and cycles of PDSAs to test the desired process measures and whether they were able to achieve the desired outcome measure. Health-care providers (HCP)-PDSA was initiated to test the success with doctors and nurses. In the HCP-PDSA first cycle, it was decided to involve only one unit lead (one consultant with his fellows and residents, a total of 4 doctors) and one nurse to test their acceptance and commitment to the concept of the project. The second cycle was intended to expand the intervention to two units' consultants (10 doctors) and new batches of nurses were involved. In the third cycle, all units' leads with their fellows and residents were included. All nurses in the hospital were involved in the training sessions. In the fourth cycle, the automatic reminders from the system were activated by the physician CDSS and a policy draft was in place.

Patient education

Patient-PDSA was created to test the progress of the intervention team with the education of patients and their families. Over the six cycles of patient-PDSA, the process measure focused on developing the awareness of patients and reducing their refusals to vaccination. Interestingly, when the country was hit drastically by Corona virus disease-2019 (COVID-19) in the middle of the project, the fear from the pandemic positively impacted the understanding of patients and their families through improving their acceptance to take the routine vaccinations to protect them against severe illnesses and minimize acute hospitalizations. [Figure 1] showed the patient-PDSA cycles with the refusal rate in a decreasing pattern over the time of the project.
Figure 1: Percentage of patients' refusals to the vaccinations as a measure for the success in delivering the education to patients/ families

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Ethical considerations

This project received an ethics waiver as a QI work from the Medical Research Center Ethics Board in HMC. All the study subjects are suffering from chronic psychiatric disorders with few could have limited or comparably lesser cognitive function and may not be fully competent to understand a written informed consent. Therefore, verbal consents/ proxies were taken from whoever was able to give or from their families, as well as the psychiatrists taking care of their health. The administrative and authoritative permissions were attained by the team to carry out this QI project.

  Results Top

We identified 50 long-term psychiatric patients who were eligible for the vaccination initiative by the intervention team. [Table 1] shows the demographics for the patients involved. From them, there were 20 patients who had both psychiatric illness and diabetes. Three patients combined both chronic respiratory disorders with psychiatric conditions. Of all patients, 40 patients were heavy smokers for 10 years or more. Except for only one immunocompromised, all patients were immunocompetent.
Table 1: Demographics of the long-term patients involved in the vaccination quality improvement project

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During the period from January 01, 2020 to December 01, 2020, patients received a total of 191 doses of all composite vaccinations (flu, pneumococcal, hepatitis B vaccines). Total due doses for all patients were calculated as 205 doses, which meant that the success rate in intervening with patients was 93%. [Table 2] showed total vaccinated patients and their percentage for each of the vaccines used before and after the intervention.
Table 2: Baseline and postintervention vaccination rate

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NNT was calculated as a proxy for the ES from the equation (100/EER – CER) where EER was the rate of vaccination postinterventions, which was 92%, and CER was the rate of vaccination in the control or as usual care preinterventions by the team, which was 10%. The calculation yielded a NNT of 1.2, suggesting that for every single patient exposed to the interventions, at least additional one will have a desirable attitude and behavior toward vaccinations than if was exposed to the usual care or control conditions.

Results related to measures of improvement

Outcome measure

The percentage of vaccinated patients increased dramatically from a baseline of 10% till exceeded the target of 90%. Over the course of the QI project during the 12 months, we reached a final vaccination rate of 92% [Figure 2]. The initial increase occurred before the outbreak season in March 2020 and the campaign was put on hold temporarily based on safety concerns from the treating psychiatrists. However, by the end of July 2020, the improvement curve started to soar up again, as physicians started to get confidence in the interventions and more understanding of circumstances.
Figure 2: The outcome measure; percentage of vaccinated patients by the end of 2020

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Process measures

The clinical pharmacists' interventions with doctors started to build up over time parallel with increasing the dispending of vaccines from the inpatient pharmacy to reach a total of 191 interventions and 191 total composite vaccination doses dispensed by the end of 2020. The rate of dispensing vaccines from the pharmacy rose from 10% to 92%. Refusals to vaccinations by patients dropped from 42% at the start of the project to 4% by the end [Figure 1].

Balancing measure

There were mild adverse events observed among patients who received the vaccines. The adverse effects were mostly myalgia, injection site pain, low-grade fever which subsided 24-h postadministration of the vaccines.

  Discussion Top

Vaccines have shown to be instrumental in decreasing the burden on the health-care system in terms of cost, morbidity, and mortality that is associated with vaccine-preventable diseases such as pneumococcal diseases, influenza, and hepatitis. Thus, the QI team set out to design a process to achieve the goal of improving the percentage of long-term patients in MHS who received their routine vaccination by the end of 2020 to attain a 90% compliance rate with all vaccination types needed. MHS did not have an established routine vaccination process before this initiative. The improvement team worked through multiple PDSA cycles with each cycle serving to identify the strengths and areas of improvement needed in the subsequent cycle. Change is possible when well-designed interventions are utilized. Improvement diagnostics such as the Ishikawa analysis were used to identify potential areas for interventions in the categories of “people, process, logistics, and policy.” Measures of improvement – outcome, process, balance, were identified and defined.

The primary outcome measure increased dramatically from a baseline vaccination rate of 10% to more than our prespecified target of 90%. COVID-19 constituted a challenge for the completion of the project due to health-care providers' attitude during the first wave of the pandemic, which was characterized by uncertainty about the safety of patients with the use of the vaccines at that unprecedented time. Postvaccination Adverse drug reactions (ADRs) such as fever and body aches that mimic COVID-19 symptoms could lead to seclusion and isolation of the patients which may cause panic and, in turn, might trigger agitation or violence in the wards. The role of external factors on improvement initiatives has been discussed before in other campaigns.[17] The COVID-19 pandemic, which can be considered as an external factor, raised global awareness of the importance of vaccines in social media, and this positively impacted the understanding of patients and their families for improving their acceptance to take the routine vaccinations. This might have been a reason, along with the education of patients and families, for improving the refusal rate from 25% in March 2020 to only 4% by December 2020. Another external factor that may have had an impact on improving the refusal rate of vaccines could be due to the proximity of inpatients to the health-care workers. It has been shown before that interaction with the health-care workers increase the vaccination rates.[18] Therefore, the fact of in-house vaccination could have caused increased uptake of the vaccines.

Standing orders of vaccines have shown to be the most successful intervention in increasing the vaccination rates.[19] This makes the results applicable to most organizations today who also utilize an electronic medical system, keeping in mind that a multidisciplinary approach will still be required to apply the standing orders and maximize the usefulness of the EMR.

A couple of roadblocks we encountered during the implementation of the improvement efforts. Firstly, we faced some delays due to the emergence of the COVID-19 pandemic during the project. The project had to be temporarily put on hold owing to some uncertainties with postvaccination ADRs that the patients might experience. These potential ADRs could mimic COVID-19 symptoms and lead to isolation of the psychiatric patient which may, in turn, further complicate the situation by triggering violence and aggression. Second, some issues were faced with securing the zoster vaccines as it was restricted only for the Communicable Diseases Center's patients in Qatar. These restrictions should be re-evaluated by the high-level management to provide equitable care for all patients. Finally, certain deficiencies in the system's CDSS were noted. The CDSS currently used does not have a system to automatically alert the treating team regarding a due date for a vaccine. Moreover, the CDSS also lacks an accurate method to document vaccine refusal or if the patients received vaccinations at another location other than HMC. The hospital administration may need to work with CDSS providers to resolve these logistical issues so that patients can receive the best care possible. Although we are believed that local efforts helped to improve the vaccination rate, external factors such as the COVID-19 pandemic may have weakened the ability to respond more readily to the implemented changes. Understanding all of the relevant factors that lead to vaccination uptake can be applied for future hospital vaccination campaigns.

  Conclusion Top

In conclusion, external factors such as COVID-19 outbreak and subsequent vaccination awareness may have served the implementation strategies efficiently. The success rate over a 12-month period can prove that the interventions were effective despite the interference of external factors. This QI project suggests that educational interventions with health-care staff, patients, and families regarding vaccinations can produce improvements in the vaccination rates. The sustainability of the results can be achieved by designating champions in each unit and drafting policies on the physical health care of psychiatric patients. These results may be useful to hospitals considering vaccine implementation or those currently struggling with implementation barriers.


The research team would like to many thanks and gratitude for Mr. Hesham Mohamed, infection control practitioner and Mr. Shiju Ramapurath, clinical nurse specialist, Mr. Mohamed Hamidah, senior quality reviewer, and Ms. Pauline Cadampog, quality reviewer for their dedication and commitment during the work on the quality improvement project.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  Appendix 1 Top

  References Top

A Brief History of Vaccination | Immunisation Advisory Centre. Available from: https://www.immune.org.nz/vaccines/vaccine-development/brief-history-vaccination. [Last accessed on 2021 May 26].  Back to cited text no. 1
Immunization Basics | CDC. Available from: https://www.cdc.gov/vaccines/vac-gen/imz-basics.htm. [Last accessed on 2021 May 26].  Back to cited text no. 2
Vaccine Preventable Adult Diseases | CDC. Available from: https://www.cdc.gov/vaccines/adults/vpd.html. [Last accessed on 2021 May 26].  Back to cited text no. 3
Vaccines and Immunization. Available from: https://www.who.int/health-topics/vaccines-and-immunization#tab=tab_1. [Last accessed on 2021 May 26].  Back to cited text no. 4
MacDonald N, Mohsni E, Al-Mazrou Y, Kim Andrus J, Arora N, Elden S, et al. Global vaccine action plan lessons learned I: Recommendations for the next decade. Vaccine 2020;38:5364-71.  Back to cited text no. 5
Doherty M, Schmidt-Ott R, Santos JI, Stanberry LR, Hofstetter AM, Rosenthal SL, et al. Vaccination of special populations: Protecting the vulnerable. Vaccine 2016;34:6681-90.  Back to cited text no. 6
Brown JD, Bell N. Role of psychiatric hospitals in the equitable distribution of covid-19 vaccines. Psychiatric Services 2021;72:1080-3.  Back to cited text no. 7
Warren N, Kisely S, Siskind D. Maximizing the Uptake of a COVID-19 Vaccine in People With Severe Mental Illness: A Public Health Priority. JAMA Psychiatry 2021;78:589-90.  Back to cited text no. 8
Druss BG, Rosenheck RA, Desai MM, Perlin JB. Quality of preventive medical care for patients with mental disorders. Med Care 2002;40:129-36.  Back to cited text no. 9
Miles LW, Williams N, Luthy KE, Eden L. Adult vaccination rates in the mentally ill population: An outpatient improvement project. J Am Psychiatr Nurses Assoc 2020;26:172-80.  Back to cited text no. 10
Young S, Dosani N, Whisler A, Hwang S. Influenza vaccination rates among homeless adults with mental illness in Toronto. J Prim Care Community Health 2015;6:211-4.  Back to cited text no. 11
Ministry of Public Health – National Health Strategy 2018 – 2022. Available from: https://www.moph.gov.qa/english/strategies/National-Health-Strategy-2018-2022/Pages/default.aspx. [Last accessed on 2021 May 26].  Back to cited text no. 12
Cook RJ, Sackett DL. The number needed to treat: A clinically useful measure of treatment effect. BMJ 1995;310:452-4.  Back to cited text no. 13
Laupacis A, Sackett DL, Roberts RS. An assessment of clinically useful measures of the consequences of treatment. N Engl J Med 1988;318:1728-33.  Back to cited text no. 14
Ogrinc G, Davies L, Goodman D, Batalden P, Davidoff F, Stevens D. SQUIRE 2.0 (Standards for QUality improvement reporting excellence): Revised publication guidelines from a detailed consensus process. BMJ Qual Saf 2016;25:986-92.  Back to cited text no. 15
Pinnock H, Barwick M, Carpenter CR, Eldridge S, Grandes G, Griffiths CJ, et al. Standards for reporting implementation studies (StaRI): Explanation and elaboration document. BMJ Open 2017;7:e013318.  Back to cited text no. 16
Grol R, Grimshaw J. From best evidence to best practice: Effective implementation of change in patients' care. Lancet 2003;362:1225-30.  Back to cited text no. 17
Winston CA, Wortley PM, Lees KA. Factors associated with vaccination of medicare beneficiaries in five U.S. communities: Results from the racial and ethnic adult disparities in immunization initiative survey, 2003. J Am Geriatr Soc 2006;54:303-10.  Back to cited text no. 18
Trick WE, Das K, Gerard MN, Charles-Damte M, Murphy G, Benson I, et al. Clinical trial of standing-orders strategies to increase the inpatient influenza vaccination rate. Infect Control Hosp Epidemiol 2009;30:86-8.  Back to cited text no. 19


  [Figure 1], [Figure 2]

  [Table 1], [Table 2]


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