Table 3.

Examples of Interview Responses by Practice Classification Using the RE-AIM Framework

RE-AIM Component	Corresponding 4 Pillars™ Strategy	Low Implementers	Moderate Implementers	High Implementers
Reach	Patient Notification Express vaccination services.	Staff members report that patient notification is not needed because “patients just know” that flu shots are recommended and available.	Flu clinics are scheduled “when there is room in the schedule or when physicians are on vacation.”	MAs have stopped asking “Do you want your shot?” and instead ask, “Did the doctor already give you your shot?” When patients call to ask about flu shots, they are asked “When do you want to come in?” to ensure low-threshold access.
Effectiveness	Evidence based practices are used, including standing orders.	As noted by one Office Manager, “I am not sure MAs will ever be comfortable doing immunizations without physician approval.”	Although standing orders for immunizations are in place, Medical Assistants express discomfort in administering immunizations without checking with the physician first. Immunizations are “pended” in EMR rather than administered via standing orders.	Standing orders were implemented for Tdap after a successful experience implementing standing orders for influenza. As per one Immunization Champion, “It’s just a matter of implementing a new process.”
Adoption	Strategies are encouraged via staff training and the creation of an IC role.	IC is not a practice leader but was placed in this role by default: “I went to Disney, I came back, and Bam! I was the Immunization Champion…I’m not sure what I’m supposed to do.”	IC responsibilities are limited to administrative tasks; no leadership or motivational role.	IC is recognized as an informal and natural leader. She is on top of the administrative and managerial aspects of getting this study off the ground, but also encourages whole team approach. Her supervisor noted that the IC is naturally enthusiastic and encouraging, so people “just fall into step behind her.” This IC also developed a process for streamlining immunization, documenting, VIS, and discharge to make this process work smoother.
Implementation	Ongoing support through regular conference calls and online 4 Pillars™ Program.	IC states that she is “Not sure about all of this” and that “No one has time in this office to sit and read articles or to watch videos.”	Online 4 Pillars™ Program is used primarily for tracking progress and checking off completion of steps.	Online 4 Pillars™ Program is used to gather ideas and develop tools for planning.
Maintenance	Motivation through monthly progress charts.	Progress as documented through charts is not shared with staff.	IC notes that at some point she might share graphs more consistently but right now “staff is not very interested in them.”	IC shared with MAs during a morning informal huddle: “Hey, guys, we got the highest percentage in Tdap and flu! Congratulations!”

Note: EMR=electronic medical record; IC=Immunization Champion; MA=medical assistant