Improving pneumococcal vaccination uptake in a residency clinic: a case-inspired QI initiative aligned with updated CDC guidelines

Abstract

Streptococcus pneumoniae remains a leading cause of preventable morbidity and mortality among adults, particularly those with chronic medical conditions, yet pneumococcal vaccination uptake in adult populations remains suboptimal. Residency-based primary care clinics face unique barriers to preventive care delivery, including staffing instability and competing clinical priorities. After identifying pneumococcal vaccination rates in our internal medicine residency clinic that were lower than the national average, we conducted a quality improvement initiative to increase vaccination uptake. Using Plan–Do–Study–Act cycles from September 2024 through February 2025, we implemented targeted, system-level interventions including certified medical assistant–led pre-queuing of pneumococcal vaccine orders, passive patient education via waiting room slideshows and quick response (QR) codes, and structured resident reminders through daily huddles and email reinforcement. Vaccination rates were tracked bi-weekly using electronic medical record data and analysed with run charts. Among adults aged ≥65 years, vaccination rates increased modestly from 62.7% to 64.3%. Following expansion of vaccine eligibility to adults aged ≥50 years, baseline vaccination rates decreased to 39.9% due to the enlarged eligible population; however, rates subsequently increased to 44.1% by the end of the intervention period, representing a 4.2% absolute improvement and meeting criteria for a sustained run chart shift. These findings demonstrate that small, multidisciplinary, workflow-integrated interventions can produce meaningful and sustainable improvements in adult pneumococcal vaccination uptake in residency clinic settings and may be adaptable to other resource-limited primary care environments.

WHAT IS ALREADY KNOWN ON THIS TOPIC

• Streptococcus pneumoniae remains a leading cause of severe illness and death in adults, particularly among those with chronic conditions. Vaccination is proven to reduce morbidity and mortality, yet adult vaccination rates remain suboptimal nationwide and in Illinois. Resident-run clinics face unique barriers, including staffing instability and competing resident priorities, leading to lower vaccination uptake. The Center for Disease Control’s (CDC) recent expansion of pneumococcal vaccine eligibility to adults aged ≥50 years further underscores the need for system-level improvements.

WHAT THIS STUDY ADDS

• This quality improvement project demonstrates that small, targeted interventions—such as certified medical assistant (CMA)-led vaccine order pre-queuing, passive visual patient education (waiting room slideshow) and structured resident reminders—can incrementally increase vaccination rates. The project successfully established sustainable workflows, demonstrated the value of multidisciplinary engagement and provided important insights into barriers unique to residency clinics, while also achieving improvements in vaccination rates.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

• The findings reinforce that embedding vaccination strategies into daily workflows and empowering support staff are essential for improving uptake. This model is adaptable to other residency or resource-limited clinics facing similar challenges. Future research may include scalable interventions such as electronic medical record (EMR) automation, patient outreach campaigns and community engagement initiatives. At the practice and policy level, providing structured support for resident clinics—such as staffing stability and decision-support tools—may help strengthen vaccination efforts and contribute toward broader public health goals.

Introduction

An unexpected death from invasive pneumococcal pneumonia in our institution prompted critical reflection on our clinic vaccination processes. The patient met established criteria for vaccination based on age and comorbidities; however, review of their records revealed no prior immunisation. This case highlights the importance of vaccination, for reducing preventable morbidity and mortality and the need to reliably deliver high-quality guideline-concordant care. Strengthening vaccination against pneumococcal disease, especially in high-risk populations, is critical to improving patient outcomes, reducing preventable diseases and minimising both clinical and public health risks. Streptococcus pneumoniae is responsible for invasive diseases such as bacteremia and meningitis, with case fatality rates ranging from 40%–60% and 8%–22% respectively.¹ These rates are significantly higher among adults with underlying comorbidities, like chronic kidney disease which showed notably high incidence rate ratios (IRR) of 18.40 (95% CI 11.38 to 29.74) with significant increase observed for diabetes.² In adults over 65 years, the pneumococcal vaccine has been shown to be an independent protective factor, significantly reducing mortality-related pneumonia (OR 0.59; 95% CI 0.390 to 0.921) with a reduction in all-cause hospitalisation (OR 0.94; 95% CI 0.91 to 0.97), particularly among individuals aged ≥75 years and those with chronic comorbidities.^{3 4} Despite these proven benefits, vaccine uptake remains suboptimal. According to the Center for Disease Control (CDC) 2022 data, nationally 64% of adults 65 and older received the vaccine, with slightly higher coverage in Illinois (IL) at 67%.^{5 6}

In the same year, CDC reported that adults aged 50–64 years experienced invasive pneumococcal disease (IPD) incidence rates of 13.2 per 100 000 population and mortality rates 1.8 per 100 000 population—which approaches rates observed in the ≥65-year population. As a result, the 2024 guidelines were updated to expand vaccination recommendations to include this population.⁷

At Carle Foundation Hospital’s Internal Medicine Resident Program (IMRP) clinic in Champaign, IL, we noted that our pneumococcal vaccination rates lagged national and state level rates. In August 2024, only 62.7% (261/416) of eligible patients had been vaccinated, slightly low compared with above mentioned state and national average. Data obtained after the guideline update in October 2024 revealed a larger discrepancy: the IMRP clinic revealed pneumococcal vaccination rates of 39.9% (491/1230)_ for adults ≥50 years old. These disparities revealed a critical need for targeted, system-level improvement within the IMRP clinic.

Specific aims

We undertook this quality improvement project to increase vaccination uptake among eligible adults an outpatient internal medicine residency clinic.

Our Specific, Measurable, Achievable, Relevant, Time-bound (SMART) aim was to increase the proportion of eligible adults aged ≥65 years who had received a pneumococcal vaccine by 5% from a baseline of 62.7% over 3 months. Following the implementation of updated CDC guidelines, this SMART aim was revised to increase pneumococcal vaccination rates by 5% among eligible adults aged ≥50 years from a baseline of 39.92% over a subsequent 3-month period.

Methods

Context

The Plan–Do–Study–Act method was used to conduct this quality improvement (QI) study within the Carle Foundation Hospital Internal Medicine Residency Program (IMRP) clinic located in Champaign, IL. This clinic employs two physician co-directors, three full-time registered nurses (RNs), and four certified medical assistants (CMAs). Of note, at the start of this quality improvement study, the clinic had one certified medical assistant and used floating assistants. Residents have a panel of approximately 150 patients and evaluate 6 to 12 patients per day. The clinic uses a core group of 10 precepting attending physicians with whom the residents discuss their patient treatment plan. These physicians are a combination of primary care physicians, hospitalists and internal medicine specialists.

This study was conducted from 3 September 2024 to 14 February 2025, at the IMRP clinic.

Our project earned a quality improvement determination by the Carle Institutional Review Board and data collection followed all quality improvement guidelines and relevant institutional regulations.

Intervention

Our study stakeholders involved a multidisciplinary group including resident physicians, attending physicians, CMAs and RNs. These stakeholder members were supported by clinical informatics personnel, the IMRP clinic coordinator, administrative staff, a statistician and a quality improvement coach through the American College of Physicians (ACP) Raise the Rates CDC grant-funded programme (spanning April 2024 to March 2025).

We held three stakeholder meetings to generate process maps and fishbone diagrams aimed to understand the current state of operations, identify barriers and areas for improvement (table 1). Possible interventions derived from these meetings were placed in a prioritisation matrix to systematically compare and choose next steps (online supplemental material)

Table 1. Contributing factors to low pneumococcal vaccination rates in IMRP clinics.

Factors	Details	Contribution to low vaccination rate
Processes	Patients’ eligibility for pneumococcal vaccination was not consistently identified during visits.	Absence of systematic patient reminders Absence of updated electronic medical record alerts Absence of structured screening for immunisations during rooming
Environment	Limited patient awareness of pneumococcal vaccines with fewer patient-led discussions.	Absence of visible educational materials (eg, posters, flyers, digital prompts) in IMRP clinic.
Patients	High no-show rates in IMRP clinic range from 19.1% to 23% (consistent with other residency clinics which range from 17% to 33%)13. Patients deprioritised vaccination discussions during appointments.	Vaccines not given if patients not physically in clinic Knowledge barrier Deprioritisation due to acute care focus
Physicians factors	Cognitive biases such as assuming patient disinterest, time pressure or discomfort with vaccine counselling.	Avoidance or minimisation of vaccine discussions Deprioritisation due to acute care focus
Policy	Workflow requires a resident physician to complete multiple rooming tasks.	Deprioritisation of preventative care orders, including vaccinations Lack of CMA or RN empowerment to place orders

CMA, certified medical assistant; IMRP, Internal Medicine Residency Program; RN, registered nurse.

Patients and the public were not directly involved in the design, conduct, reporting or dissemination plans of this quality improvement project. The interventions were implemented at the system and workflow level within the residency clinic. Patients were indirectly engaged through educational materials (eg, waiting room slideshow, QR codes) but they did not participate in study design or data analysis.

Early in the planning process, we engaged CMAs, residents, faculty, pharmacists and clinic leadership to ensure goal alignment and feasibility. Interventions were introduced through existing clinic structures including morning huddles, staff meetings and residency conferences to reduce disruption and promote buy-in.

The project unfolded over multiple iterative Plan–Do–Study–Act (PDSA) cycles as outlined in table 2.

Table 2. PDSA cycles.

Cycle	Plan	Do	Study	Act
Cycle 1:	Low IMRP vaccination rates were identified. Hypothesised that allowing immunisation orders to be queued prior to visit would improve vaccination rates. Similar workflows completed in Carle Foundation Hospital Internal Medicine and Family Medicine Faculty clinics.	09/03/2024: CMAs identify patients in need of pneumococcal vaccination and queue orders during pre-visit calls or rooming	Modest increase in immunisation. Implementation inconsistent due to limited staffing (one full-time CMA until 10/21/2024)	Continue order queuing via standardised IMRP CMA clinic workflow for permanent and floating staff
Cycle 2:	CDC updated eligibility guidelines (≥50 years eligible). Plan to adjust data tracking and re-educate staff.	10/26/2024: Staff informed via regularly scheduled meetings and adjusted processes to reflect expanded eligible patient pool.	Vaccination rate decreased due to increased eligible patient pools.	Adjust Specific, Measurable, Achievable, Relevant, Time-bound (SMART) aim.
Cycle 3:	Increase patient awareness and promote vaccine-related discussion via passive patient education in waiting room	11/02/2024: Launched patient-facing vaccine slideshow on clinic waiting room screens	No rapid uptake observed	Continue and refresh the slideshow. Expand passive patient education tools.
Cycle 4:	Increase patient and staff awareness and promote vaccine-related discussion via QR codes in patient waiting areas and staff workrooms	11/15/2024: Deployed Quick response (QR) codes linking to electronic surveys and CDC materials	Low engagement.	Deprioritise as standalone intervention.
Cycle 5:	Improve resident participation in vaccine discussions and ordering.	11/20/2024: Added vaccine reminders to morning huddles and sent email reinforcements	Alone, impact was limited. Helped sustain awareness and layered well with other interventions.	Maintain reminders as part of the resident education strategy. Incorporate into long-term clinic workflow.

CDC, Center for Disease Control; CMA, certified medical assistant; IMRP, Internal Medicine Residency Program; PDSA, Plan–Do–Study–Act.

Study of the intervention(s)

Data were obtained through Population Analyzer, a data collection tool that derives information from Epic Electronic Medical Records, every 2 weeks. Preintervention data on baseline vaccination rates were captured for IMRP clinic from 6 weeks prior to the start of intervention. Vaccination data from previous year were not included in this study. Additionally, the implementation of the intervention was assessed informally throughout the study through regular check-ins with all stakeholders.

Measures

Primary Outcome Measure: The primary outcome measure was the percentage of patients within the Carle IMRP clinic who received at least one vaccine against Streptococcus pneumoniae. Our definition of rates of pneumococcal vaccinations was based on a combination of Centers for Medicare & Medicaid Services quality measures and previously published quality definitions.⁸ We calculated the number of eligible patients by determining the number of established IMRP clinic patients aged ≥65 years by the end of our measurement period (denominator). We then determined the number of patients who received a vaccination on or after their 60th birthday and by the end of the measurement period (numerator). Our vaccination rates were calculated by dividing the numerator by the denominator. This calculation was updated to locate patients aged ≥50 years with the initiation of the new CDC guidelines.⁹

Process Measures: To assess the implementation of the CMA-driven vaccination workflow (PDSA cycle 1), process measures focused on clinician awareness of pre-queued pneumococcal vaccine orders (“Were pneumococcal vaccine orders pre-queued for your patient, when appropriate?”). These data were gathered through a survey administered during a resident didactic session.

Balancing Measure: To ensure that the intervention did not inadvertently increase workload for CMAs, a balancing measure was used to track the time required for CMAs to complete pre-visit planning and rooming tasks. Two CMAs were asked to self-time their interactions with patients before and after implementation of the revised workflow, including time spent screening for pneumococcal vaccine eligibility and queuing orders. This measure aimed to detect any unintended burden introduced by the workflow change and inform necessary adjustments to maintain operational efficiency.

Analysis

Data were gathered and analysed bi-weekly via run charts to assess vaccination rates over time. Run chart rules were applied to determine whether observed changes over time were significant. Based on the updated CDC recommendations and adaptation of our outcome measure, we created two run charts. One run chart demonstrates our outcomes in patients ≥65 years (before the updated CDC recommendations) and another run chart demonstrates our outcomes in patients ≥50 years (after the updated CDC recommendations). Each chart indicates the timing of PDSA cycles, clinic changes and vaccine recommendations.

Results

The project began with a CMA-driven workflow in which CMAs pre-queued pneumococcal vaccine orders for eligible patients during pre-visit calls or rooming. Of note, the 20-valent pneumococcal conjugate vaccine had become available in this clinic just prior to this intervention. Additionally, only one full-time CMA was available throughout September and October. At the beginning of the first PDSA cycle, the IMRP vaccination rate was 62.7% (261/416) (figure 1a).

Figure 1. (a) Run chart showing baseline pneumococcal vaccination rates at the Internal Medicine Residency Clinic prior to the updated CDC guidelines. (b) Run chart showing baseline pneumococcal vaccination rates at the Internal Medicine Residency Clinic after the updated CDC guidelines 26 October 2024. CDC, Center for Disease Control; CMA, certified medical assistant; PDSA, Plan–Do–Study–Act.

As a process measure and to assess early adoption, a brief interview was conducted with residents. Five residents per day over 3 days, for a total of 15 residents, responded. 12 of the 15 residents (80%) reported that vaccination orders had been pre-queued for their patients.

Balancing measures related to workflow efficiency were assessed through brief interviews with two CMAs. Both reported that pre-clinic screening phone calls or in-visit rooming tasks required approximately 7–8 min per patient. This duration was similar before and after implementation of the workflow. CMAs noted that pneumococcal vaccination screening consisted primarily of a brief yes/no question and direct queuing of orders, allowing the process to be incorporated seamlessly into existing workflows.

The second PDSA cycle coincided with the CDC guideline update, which expanded eligibility to all adults aged 50 years and older. This change considerably reset the IMRP clinic baseline rate to 39.9% (491/1230). To address the impact of the guideline change, the team redefined the SMART aim and staff was informed via regularly scheduled meetings. The CMA workflow was adjusted to reflect the expanded patient pool.

Between PDSA cycle 1 and the guideline expansion, vaccination rates among patients aged 65 years and older increased modestly from 62.7% to 64.3% (figure 1a). However, this change did not meet run chart criteria for special cause variation, as no sustained shift or trend was observed.

In the third cycle, passive patient education was provided via a slideshow which played in the clinic waiting room. Because of its low resource demand and steady reinforcement effect, this intervention was adapted for continued use, with plans to periodically refresh the content. During the same period, the CMA group hired two additional full-time members (total of three). The run chart demonstrated up trending values that remained below the median, suggesting early directional improvement (figure 1b).

The fourth cycle introduced QR codes displayed in waiting areas and staff workspaces which link to CDC educational materials and patient surveys. However, engagement with these materials was minimal as measured through the numbers of patient survey responses, and there was no measurable impact on vaccination rates. Given the low yield and limited practicality, this intervention was abandoned as a standalone strategy.

Lastly, the fifth cycle focused on resident engagement through structured morning huddles and email reminders. The intervention reinforced earlier strategies and supported workflow consistency. By the end of this phase, the IMRP clinic vaccination rate had increased to 44.1% (589/1335) (figure 1b), representing a 4.2% increase from the post-guideline baseline. This improvement met run chart criteria for a sustained shift.

Discussion

Summary and interpretation

In today’s healthcare climate, characterised by widespread vaccine misinformation and increasingly politicised public health recommendations, efforts to improve adult vaccination rates face significant challenges. Within this context, our resident-led clinic QI initiative demonstrated significant advances in our vaccination rates through the collaboration of CMAs, QI champions and residents.

Our interventions, particularly CMA-led workflow adaptations and clinician education, were associated with increases in pneumococcal vaccination rates. Based on the run chart shifts, it is likely that the CMA-led workflow adaptation led to the greatest amount of change within our clinic. This intervention was intentionally designed for sustainability: it was developed collaboratively with clinic staff, formally integrated into the IMRP clinic’s written protocol, and embedded into standard CMA responsibilities. Once adopted, the protocol became a durable reference for both permanent and floating staff, reducing reliance on individual champions and promoting consistency across clinic sessions. Additionally, the workflow was reinforced through daily team huddles, ensuring ongoing visibility, accountability and normalisation of vaccine discussions as part of routine care.

The clinic’s use of passive education (waiting room slide show and QR code) may have also served as a prompt for questions and patient engagement. Previous studies have demonstrated that waiting room videos may contribute to enhancement in patient knowledge, uptake or adherence.¹⁰,¹² In our clinic, these tools functioned best as adjuncts to clinician counselling rather than standalone interventions. It should also be noted that older patients within the target age range did not consistently use QR codes, limiting the reach of this strategy.

We originally planned to complete IMRP clinic patient engagement initiatives to increase the number of patients coming in for visits and vaccines. To this end, we participated in ‘Dine with a Doc’; a programme designed to provide seniors with health resources and information. This discussion did not occur until 7 May 2025, after the completion of our project. This collaboration may further enhance vaccination efforts in the future, especially through targeting of our specific clinic.

Limitations

Limitations include the unique structural challenges of resident-run clinics, such as transient clinician–patient relationships, attending preferences and high no-show rates. Staffing instability, particularly among CMAs, also disrupted early interventions, resulting in variable application of the CMA-driven workflow. The establishment of permanent CMA staffing and formal policies for pre-queuing vaccination orders enabled more reliable and sustained implementation. The denominator used for our rates included all patients with a current resident listed as the primary care physician (PCP). These patients, however, may not have had an appointment within the observed time frame. Therefore, the observed increase appears modest despite meaningful progress among patients who were seen in clinic during the observed time frame.

Additionally, the mid-cycle expansion of CDC guidelines to include adults aged ≥50 dramatically increased the eligible patient population. In the absence of electronic medical record automation or built-in clinical decision support, adapting to these changes required physicians, CMAs and nurses to complete manual chart reviews and updates. However, working in daily reminders into the huddle helped to overcome some of these challenges, however.

It can also be argued that pneumococcal vaccination rates may vary seasonally, particularly during the fall respiratory virus season when patients and clinicians are more likely to engage in preventive care discussions and receive concurrent seasonal vaccines (eg, influenza). Historical clinic-level data were not available to assess baseline seasonal trends, and some portion of the observed improvement may reflect seasonal effects rather than the interventions alone.

Ultimately, this QI initiative reframed its SMART aim, made measurable progress in building infrastructure, identified key barriers and set the stage for more sustainable improvements. The results underscore the importance of embedding vaccination efforts into routine clinic workflows. Future strategies include optimising no-show rates to enhance vaccination rates, implementing dedicated vaccine clinics, and leveraging patient portal reminders, mailed letters, events to increase awareness and accessibility.

Conclusion

The above-mentioned case of invasive pneumococcal pneumonia illustrated how gaps in preventive care persist even when patients meet clear, guideline-based criteria for vaccination. This quality improvement initiative was designed to address these missed opportunities by standardising pneumococcal vaccine assessment and delivery within routine clinic workflows. Our project demonstrated that small, incremental improvements in pneumococcal vaccination rates can be achieved through targeted, multidisciplinary interventions. Embedding these changes into routine clinic operations reduces dependence on individual motivation and increases the likelihood of long-term maintenance. This model may be adaptable to other clinics with similar patient populations and staffing challenges.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.