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An important component of a vaccine provider’s practice is 

ensuring vaccines reach all patients who need them, when 

they need them. Providers should implement systems and 

programs to provide effective vaccine delivery and to maintain 

and increase vaccination coverage in their practices. By creating 

a culture of immunization in the practice, both providers and 

patients can vaccinate with confidence.

Vaccine-preventable disease rates in the United States are at 

low levels. In 2018, four cases of rubella, one case of diphtheria, 

and 23 cases of tetanus were reported to CDC. However, the 

viruses and bacteria that cause vaccine-preventable diseases 

and death still exist. Diseases can be passed to unprotected 

persons or imported from other countries, as shown by the 

measles outbreaks that occurred in 2019 in New York and other 

states. Diseases such as measles, mumps, and pertussis can be 

more severe than often assumed, and can result in social and 

economic costs in addition to the physical costs: sick children 

miss school, parents have to take time off from work, and 

outbreaks can severely disrupt health care systems. 

Sustainable systems for vaccinating children, adolescents, 

and adults must be continued in the context of a changing 

health care environment. High vaccination coverage cannot 

be maintained with one-time or short-term efforts. Greater 

understanding of strategies to increase and sustain vaccination 

coverage is necessary to create lasting, effective immunization 

delivery systems. 

Many public health strategies have been used to increase 

vaccination coverage. Some, such as school entry laws, have 

been effective in increasing vaccination compliance, but the 

effectiveness of other strategies (e.g., advertising) is not welldocumented. Some proven strategies (e.g., reducing costs, 

linking vaccination to Women, Infants, and Children [WIC] 

services, home visits) work well to increase coverage among 

specific populations, such as persons with limited access to 

immunization services. However, creating a culture 

of immunization within a health care practice also plays 

a critical role in maintaining and increasing vaccination 

coverage, as well as ensuring vaccines are delivered safely, 

effectively, and on time.

This chapter explores strategies health care providers can 

implement within their own practices. It covers system-level 

interventions such as quality improvement programs, as 

well as practice-level actions directed toward patients and 

provider staff.

Adam Bjork, PhD and Valerie Morelli, BA

NOTES

https://www.cdc.gov/vaccines/pubs/pinkbook/strat.html Aug 2021
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Standards for Child, Adolescent, and Adult 

Immunization Practices

All health care providers in all settings are encouraged to 

ensure patients are up-to-date on vaccinations. The National 

Vaccine Advisory Committee’s (NVAC) Standards for Child 

and Adolescent Immunization Practices and Standards for 

Adult Immunization Practice are recommended for use by 

all health care providers in the public and private sectors. 

The standards represent the most desirable immunization 

practices that providers should strive to achieve, regardless 

of whether they actually provide vaccinations. Providers 

implementing these standards will help ensure their patients 

are fully vaccinated, thereby helping to increase vaccination 

coverage and prevent outbreaks. 

The Standards for Child and Adolescent Immunization Practices

outline standards within five categories:

• Availability of vaccines

• Assessment of immunization status

• Effective communication about vaccine benefits and risks

• Proper storage and administration of vaccines and

documentation of vaccinations

• Implementation of strategies to improve

vaccination coverage

The Standards for Adult Immunization Practice include the 

following four standards:

• Assess immunization status of all adult patients at every

clinical encounter

• Strongly recommend vaccines that patients need

• Administer vaccine or refer patients to a vaccine provider

• Document vaccines received by patients

The Guide to Community Preventive Services

The Community Preventive Services Task Force’s Guide to 

Community Preventive Services is a collection of evidence-based 

findings based on effectiveness data and economic evidence. 

The vaccination section of the Guide to Community Preventive 

Services describes strong or sufficient evidence to support 

several provider-based immunization strategies discussed 

throughout this chapter. 

NOTES
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Health Care Practice Quality

Improvement Programs 

Immunization quality improvement projects can be particularly 

effective because vaccination is a dynamic, critical, and 

measurable area of health care. It is rapidly evolving, making 

fast strides in some areas, but lagging in others, such as human 

papillomavirus (HPV) vaccination. 

CDC encourages health care providers to consider 

implementing immunization quality improvement projects that:

1. Generate measurable increases in child, adolescent, and 

adult vaccination coverage.

2. Bring about measurable increases in HPV vaccination 

coverage, particularly rates of coadministration with other 

adolescent vaccines at age 11 or 12 years.

3. Bring about measurable increases in vaccination coverage 

of pregnant women, specifically for influenza and 

pertussis. 

4. Reduce disparities in vaccination coverage, whether 

associated with race, ethnicity, type of health insurance 

(including lack of insurance), or any other factor resulting 

in less than optimal coverage. 

Immunization Quality Improvement for 

Providers (IQIP)

CDC works with state, local, and territorial public health 

agencies to administer the Immunization Quality Improvement 

for Providers (IQIP) program to introduce and sustain new or 

improved immunization practices. Designed to increase on-time 

vaccination at the provider level, IQIP strategies are intended to 

increase vaccine uptake among child and adolescent patients 

in adherence with the Advisory Committee on Immunization 

Practices (ACIP) routine immunization schedule. IQIP is targeted 

toward quality improvement among providers enrolled in the 

Vaccines for Children (VFC) program. 

IQIP Overview

IQIP serves to assist and support providers by identifying 

opportunities to improve vaccine uptake, determining options 

for improving immunization delivery practices, and ensuring 

providers are: • Aware of and knowledgeable about vaccination coverage 

within their practices and missed opportunities to vaccinate

• Motivated to try new immunization service delivery 

strategies and incorporate changes into their practices

• Capable of sustaining changes and improvements to their 

immunization delivery services

NOTES
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The IQIP Process

IQIP is a 12-month process where public health representatives 

and VFC providers collaborate to identify strategies to increase 

vaccine uptake by improving and enhancing immunization 

workflow. The collaborative process includes vaccination 

coverage measurement at or near the time of an initial site 

visit and again one year later to evaluate progress. Technical 

assistance and support occur at two- and six-month intervals to 

aid providers in staying on course with implementing strategies 

to improve vaccine uptake.

IQIP strategies include: • Scheduling the next immunization visit before the patient 

leaves the provider site

• Leveraging immunization information system (IIS) 

functionality to improve immunization practice

• Giving a strong vaccine recommendation for patients • Optional strategies as defined by the needs of state and 

local communities

IQIP has replaced CDC’s previous Assessment, Feedback, 

Incentives, and eXchange (AFIX) quality improvement program 

to better address the current health care environment.

Immunization Information Systems (IISs)

Many record-keeping tasks, as well as patient reminder and 

recall processes, can be greatly simplified by participation in 

an IIS. An IIS is a confidential, population-based, electronic 

database that records all vaccine doses administered by 

participating providers to persons residing within a given 

jurisdiction. In some areas, an IIS links to a complete medical 

record. While electronic health records (EHRs) include 

vaccination information, they may not provide a consolidated 

immunization history. An IIS provides a single data source 

for all community vaccination providers, enabling them to 

access records of persons receiving vaccinations from multiple 

providers. Data exchange between IISs, EHRs, and other 

information systems helps ensure timely vaccinations and 

records consolidation and allows immunization personnel to 

work more efficiently. • At the point of clinical care, an IIS can provide consolidated 

immunization histories for use by a provider in determining 

appropriate patient vaccinations. 

• At the population level, an IIS provides aggregate data on 

vaccinations for use in surveillance and program operations 

and for guiding public health action, with the goals of 

improving vaccination coverage and reducing rates of 

vaccine-preventable diseases. 

NOTES
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The Guide to Community Preventive Services recommends IISs 

based on strong evidence that their use increases vaccination 

coverage. IISs can directly contribute to efforts to increase 

vaccination coverage through their abilities to: • Create or support effective interventions such as patient 

reminder and recall systems, provider assessment and 

feedback, and provider reminders. 

• Generate and evaluate public health responses to outbreaks 

of vaccine-preventable disease. 

• Facilitate vaccine inventory management and accountability. • Determine patient immunization status to inform 

decisions made by health care providers, clinicians, health 

departments, and schools.

• Aid surveillance and investigations of vaccination 

coverage, missed vaccination opportunities, and invalid 

dose administration.

Federal, state, and local public health agencies are continuing 

their efforts to improve IISs and to increase participation by 

vaccine providers. IISs are a key to increasing and maintaining 

vaccination coverage, and they offer advantages for providers, 

patients, and state and federal immunization program staff. 

Essential Strategies for Health Care Practices

In addition to implementing a quality improvement program 

such as IQIP and participating in an IIS, other effective 

practice strategies exist that complement these programs. 

These strategies focus on patient confidence in vaccination 

and provider development of a culture of immunization 

within a practice.

Patient-Focused Strategies

Strong Vaccination Recommendation 

A strong recommendation by a health care provider is a 

powerful motivator for patients to comply with vaccination 

recommendations. A recommendation from a health care 

provider remains the number one reason parents decide to 

vaccinate. Even initially reluctant adults are likely to receive an 

influenza vaccination when the health care provider’s opinion 

of the vaccine is positive. Studies show a parent who receives a 

recommendation from their child’s health care provider is four 

to five times more likely to get the HPV vaccine for their child. 

Research has also shown the way a recommendation 

is presented makes a difference. When providers use a 

presumptive approach (one that assumes parents will choose 

to vaccinate), parents are more likely to accept vaccines than 

when a participatory approach (one that presents parents with 

NOTES
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Immunization Strategies for Healthcare Practices and Providers

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a decision to make) is used. A research study looking at health 

care provider’s interactions with parents during vaccine visits 

showed parents were more likely to express concerns when 

providers used language asking parents about their vaccination 

plans. In this study, the presumptive approach resulted in 

significantly more parents accepting vaccines for their children, 

especially at first-time visits.

In practice, a provider using a presumptive approach might 

say, “Your child needs DTaP, Hib, and hepatitis B shots today.” In 

contrast, a participatory approach might sound like, “Have you 

thought about the shots your child needs today?”

Take Time to Answer Questions

A strong recommendation will be enough to persuade many 

patients and parents to accept vaccines. However, some 

patients and parents might need more information or additional 

reassurance. An opportunity for questions should be provided 

before each vaccination. Discussion of the benefits and risks 

of vaccination is sound medical practice and providers are 

required by law to distribute vaccine information statements 

(VISs) before each dose of vaccine.

Surveys of parents of young children have shown while most 

parents plan to vaccinate on schedule, many parents still 

have questions, often related to vaccine ingredients, vaccine 

safety in general, or side effects. Data from CDC’s National 

Immunization Survey (NIS)-Teen show when parents receive a 

recommendation for HPV vaccination from their child’s health 

care provider, about a quarter of parents still choose not to 

have their child vaccinated. These parents may have concerns 

that need to be addressed about the safety or effectiveness of 

the vaccine. 

If a parent has concerns, resists following the recommended 

immunization schedule, or questions a provider’s strong 

recommendation, this does not necessarily mean they will 

not accept vaccines. Sometimes parents simply want to hear 

their provider’s answers to their questions. Providers should 

be prepared to answer parents’ questions succinctly and 

accurately, using terms parents understand. Effective, empathic 

vaccine risk communication is essential in responding to 

misinformation and concerns. It is important to remind parents 

that state laws for school or child care entry might require 

unvaccinated children to stay home from school during 

outbreaks. For patients who question or refuse vaccination, 

identifying common ground and discussing measures 

for deferring vaccination are more effective public health 

strategies than excluding these patients from a practice. 

NOTES
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Providers can also train their staff in how to address basic 

vaccine questions to help save time during vaccine discussions 

and ensure parents hear consistent messages about vaccines. 

For adults, providers can SHARE important information to help 

patients make informed decisions about vaccinations: 

• Share the tailored reasons why the recommended vaccine 

is right for the patient based on his or her age, health status, 

lifestyle, occupation, or other risk factors.

• Highlight positive experiences with vaccines (personal or in 

the practice), as appropriate, to reinforce the benefits and 

strengthen confidence in vaccination. 

• Address patient questions and concerns about the vaccine, 

including side effects, safety, and vaccine effectiveness in 

plain and understandable language.

• Remind patients that vaccines protect them and their loved 

ones from many common and serious diseases.

• Explain the potential costs of getting the disease, including 

serious health effects, time lost (missing work or family 

obligations), and financial costs.

When recommending influenza vaccine, it may also be helpful 

to explain that the vaccine can reduce the severity of illness 

among those who contract influenza.

Practice-Focused Strategies

Despite efforts by providers to adhere to appropriate 

immunization practices, there may be unknown obstacles to 

vaccination within the practice. Barriers to vaccination may be 

physical or psychological. 

Physical barriers might include inconvenient clinic hours 

for working patients or parents, long waits at a clinic, or 

transportation issues. Providers are encouraged to determine 

the needs of their specific patient population and address 

obstacles to vaccination by taking appropriate actions, such as 

extending clinic hours or holding special vaccination events. 

NOTES
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Immunization Strategies for Healthcare Practices and Providers

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Psychological barriers to health care are often more subtle but 

may be just as important. Unpleasant experiences (e.g., fear of 

injections or difficulty leaving work for an appointment) may 

lead patients to postpone receiving needed vaccines. Concerns 

about vaccine safety contribute to some parents delaying or 

refusing recommended vaccines for their children. Overcoming 

such barriers calls for both knowledge and interpersonal 

skills on the part of the provider: knowledge of vaccines, 

recommendations, and reliable sources of accurate information 

to provide to patients and parents, as well as communication 

skills to address fears and misconceptions and provide a 

supportive and encouraging environment for patients. 

System-Based Barriers

Missed Opportunities

Another obstacle to vaccination is a missed opportunity at a 

health care encounter in which a person is eligible to receive a 

vaccine but is not vaccinated completely. Missed opportunities 

can occur in all settings in which vaccines are offered, whether 

routine or not. 

Missed opportunities occur for several reasons. Many health 

care providers avoid simultaneous administration of multiple 

injectable vaccines, frequently citing concerns about reduced 

immune response, adverse events, or perceived parental 

objections. These concerns are not supported by scientific 

data. Providers might even be unaware a child or adult needs 

a vaccination. In addition, providers sometimes follow invalid 

contraindications. A list of conditions incorrectly perceived as 

contraindications or precautions can be found in ACIP’s 

General Best Practice Guidelines for Immunization. 

Some reasons for missed opportunities relate to larger 

system issues, such as policies of only vaccinating children 

at well-care visits or not vaccinating siblings. Other reasons 

relate to institutional or bureaucratic regulations, such as 

state insurance laws denying reimbursement if a vaccine 

is administered during an acute-care visit. Several studies 

have shown eliminating missed opportunities could increase 

vaccination coverage by up to 20%. 

Providers should implement systems to ensure the practice 

never misses an opportunity to vaccinate. Establish a policy to 

vaccinate at every visit, not just well visits, and schedule the 

next vaccination appointment before the patient leaves. 

NOTES
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Adult Vaccination Barriers

Recognized barriers to adult vaccination include:

• Limited access to health care

• Multiple competing priorities for providers who care for 

adult patients

• Low awareness among adults about recommended 

vaccines and their benefits

• Challenges in coordinating care for adults who often have 

more than one medical provider

• A complicated adult immunization schedule

• Vaccine cost and reimbursement

Professional societies such as the American College of Physicians 

and American College of Obstetricians and Gynecologists 

have developed programs to support providers in improving 

vaccination coverage among their patients. These organizations 

and the National Adult and Influenza Immunization Summit

offer educational resources, tools, and strategies to overcome 

challenges to vaccinating adults. 

Creating a Culture of Immunization within 

a Practice

Creating a culture of immunization means including every 

member of the practice in vaccination efforts through:

• Consistent messaging about the importance of vaccines 

and about vaccine effectiveness and safety at all levels of 

the practice

• Adherence to proper vaccine storage, handling, and 

administration procedures

• Implementation of effective workflow processes to take 

advantage of every opportunity to vaccinate

Practices fostering support for vaccination:

• Save time.

Less time spent in vaccine conversations by involving 

practice staff in reinforcing vaccine recommendations and 

implementing effective workflow processes

• Save money.

Less money spent on lost vaccine by adhering to proper 

vaccine storage, handling, and administration practices

• Empower families.

Strengthened trust with families by helping patients and 

parents make informed decisions

NOTES
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Immunization Strategies for Healthcare Practices and Providers

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Immunization Coordinator 

It is an immunization delivery best practice for every 

provider setting to designate an immunization coordinator. 

This individual should be the provider site’s point person for 

activities such as:

• Ensuring all vaccines are stored and handled correctly 

within the practice

• Helping to ensure all staff are trained in their role in 

immunization delivery and patient education

• Monitoring the practice’s vaccination coverage

• Ensuring all staff know how to address questions from 

patients and parents so there is consistent messaging 

about vaccines

• Promoting and motivating staff implementation of 

immunization quality improvement strategies to improve 

immunization workflow, delivery, and, ultimately, 

vaccine uptake

By being familiar with the practice’s vaccination coverage 

and understanding more about why some patients are not 

up-to-date with their vaccines, providers can implement 

interventions to increase coverage in their practice.

Vaccines for Children (VFC) Program

Cost can be a barrier to vaccination for many patients. 

In addition to evaluating the fee schedules for possible 

adjustments, providers should be knowledgeable about the 

VFC program, the state’s Children’s Health Insurance Program, 

and other vaccine-focused programs available within their 

jurisdiction. 

A provider should consider participating in the VFC program 

if the practice sees children and adolescents (age 18 years or 

younger) who meet one or more of the following criteria:

• Medicaid-eligible

• Uninsured

• American Indian or Alaska Native

• Underinsured (only eligible to receive vaccines in a federally 

qualified health center or rural health clinic)

Being a VFC provider reduces up-front costs because practices 

are provided vaccines for VFC-eligible children at no cost. 

Providers can charge an administrative fee to offset the cost of 

doing business. VFC-eligible patients benefit because they avoid 

having to go somewhere else to get the vaccines they need. 

NOTES
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Vaccination Reminders for Providers 

Providers can create reminder systems to help them 

remember which vaccinations a patient needs. Examples 

of reminder systems are:

• A computer-generated list that notifies a provider which 

children being seen during the clinic session are past due 

on vaccinations

• A stamp with a message such as “no pneumococcal vaccine 

on record” that staff can put on the chart of a person age 65 

years or older

• A “vaccination due” clip that staff attaches to the chart of an 

adolescent who has not had HPV vaccine

• An electronic reminder that appears when a provider 

accesses an electronic health record

Reminder systems vary according to the needs of the provider. 

In addition to raising vaccination coverage in the practice, 

systems serve to heighten staff awareness of the need to 

continuously check the vaccination status of their patients. 

Standing Orders 

Standing orders are protocols whereby nonphysician medical 

personnel may vaccinate patients without direct physician 

involvement at the time of the vaccination. Standing orders are 

implemented in settings such as clinics, hospitals, and long-term 

care facilities. Standing orders have had positive effects on 

vaccination coverage among children and adults. 

Standing order protocols should:

• Identify persons eligible for vaccination based on their age, 

their immunization status, or the presence of a medical 

condition putting them at high risk. 

• Provide adequate information to patients or their parents 

regarding the risks and benefits of a vaccine and document 

the delivery of that information.

• Record patient refusals or medical contraindications.

• Record administration of a vaccine(s) and any 

postvaccination adverse events, according to institutionor physician-approved protocol.

• Provide documentation of vaccine administration to 

patients and their primary care providers.

Standing order protocols should also specify that vaccines be 

administered by health care personnel trained in screening 

patients for contraindications to vaccination, administering 

vaccines correctly, and monitoring patients for adverse events in 

accordance with state and local regulations.

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Immunization Strategies for Healthcare Practices and Providers

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Staff Education

Anyone responsible for administering vaccines should be 

knowledgeable about immunization principles, scheduling, 

safety and effectiveness, and proper administration techniques. 

Starting with the front office, each staff member should be 

aware of the importance of vaccines, educated on proper 

immunization practices and recommendations, and prepared to 

answer patient questions as related to their position. Numerous 

educational materials in a variety of formats are available from 

CDC and some state, local, and territorial health departments, 

hospitals, and other professional organizations. 

Record-Keeping

Patient records are essential to a medical practice, and 

maintaining these records remains a critical part of providing 

optimal health care. Immunization records in particular must be 

accurate and meet all applicable legal requirements, as well as 

requirements of any specific program (such as the VFC program) 

in which the provider participates. These records should be 

available for compliance inspections and should be easy to 

interpret by anyone examining them. 

Active medical records must reflect which patients are actually 

in the practice, and charts of persons who have moved or 

are obtaining services elsewhere should be clearly marked 

or removed. Records should be kept up to date as new 

vaccinations are administered, and all information regarding 

each vaccine and its administration should be complete.

Because patients often receive vaccines at more than one 

provider’s office, communication between sites is essential 

for maintaining complete and accurate vaccination records. 

School-based, public health, and community-based vaccination 

sites should communicate with primary care personnel through 

quick and reliable methods. IISs provide the most seamless 

and comprehensive avenue for sharing information; however, 

e-mail, telephone, or fax can also be used. Using an IIS or other 

mechanism is increasingly important as more venues outside 

the medical home offer vaccinations.

NOTES
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Acknowledgements

The editors would like to acknowledge Jennifer Hamborsky, 

Ginger Redmon, Tom Shimabukuro, and Skip Wolfe for their 

contributions to this chapter. 

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NOTES