Physical Vaccine Inventory vs. NCIR- Improving Accuracy of Inventory Reports

NAME OF HEALTH DEPARTMENT: New Hanover County Health Department

PROJECT TITLE: Physical Vaccine Inventory vs. NCIR- Improving Accuracy of Inventory Reports

Trena Ballard
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Project Overview

Project Aim:
Inventory accountability is an important aspect of responsible Public Health service administration.  The aim of this project is to improve the accuracy of inventory reports generated by the North Carolina Immunization Registry (NCIR) and assure the balancing of those reports with the New Hanover County Health Department’s (NHCHD) physical inventory counts by August, 2011.  The NHCHD quality improvement team will use the QI101 training program and the Lean Kaizen event support team to design, test and implement changes to our current reporting and inventory processes.


  • Decrease the variance between the physical inventory and the NCIR reported inventory by 90%.
  • Increase the accuracy of data entered into NCIR and on encounter forms by providers by 95%
  • Decrease the variance in multi-dose vial counts by 95% (by August 2011 for all but flu, which will be accomplished by October 2011)
  • Increase the consistency in # of doses extracted from multi-dose vials to 100% via staff training
  • Develop a consistent policy/procedure for correcting inventory discrepancies

Project timeframe:
March 2011 to January 2012

How was the need for the project determined?
Each time Fiscal team and Immunization Coordinator would do the daily, weekly or monthly inventory; there were always variances between the physical count and NCIR. The variances could not be accounted for.  Our agency felt that we needed to update policies, streamline the process and eliminate distractions.

Does this quality improvement project link to accreditation?
Yes. Activity 15.4: The local health department shall assess the internal and external resources that are available or needed to implement proposed new or updated policies and procedures.  We updated and had approved three policies during this project.

Areas for Improvement and Change Ideas Implemented

Improvement 1
All staff to retrieve the same dosages from each multi-dose vial (see Figure 1)    

  • Train staff (using new video) on instructions for drawing doses of vaccine from multi-dose vials
  • Always look for latest new guidance from the CDC… they change!
  • New Policy/Procedure: Withdrawing Vaccine from Multi-Dose Vials

Improvement 2
Reduce distractions

  • Train Customer Care staff:  Vaccine Coordinator attend CC staff meetings to update on new information and answer questions
  • Store herpes cultures in lab refrigerator to avoid staff entering general clinic room to access them in vaccine refrigerator
  • Add sliding door signs  "Occupied/ Vacant" or similar
  • Add small copier to physician's office or elsewhere
  • Customer Care staff:  instruct staff to go to  1)  to Supervisor  2) Follow-Up Nurse   3) Triage Nurse with questions
  • Adding lock to 2nd door in General Clinic office # 2 between Physician's Office

Improvement 3
Reduce encounter errors (see Figure 2)

  • Revise Encounter form for immunizations
  • Implement new process to ensure NCIR is quickly updated with corrections to encounters
  • Supervisor receives errors to address as performance issue if necessary
  • Implement a standard desktop easel tool to maintain current knowledge of eligibility and encounter coding

Improvement 4
Inventory enhancements

  • Outreach vaccines must be entered into NCIR at time of event and encounters into HIS within 24 hours
  • Implement new Vaccine log
  • Post-training QA / inspection for specific period of time to ensure understanding and accuracy
  • Flu:  individual nurses have own bag /supply of vaccine and sign it in/out for checks/balances
  • Implement revised wasted vaccine log
  • Implement walk-thru during flu clinic at end of day to check refrigerators (with sign-off sheet) to ensure no vaccine is left behind in auditorium and to check temperature
  • Track the encounters that are out to nurses for correction to ensure they are returned before inventory is taken (check copies of encounter before running report)
  • New Policy/Procedure: Immunization Documentation - Quality Assurance
  • Revised Policy/Procedure:  Outreach Events
  • Transfer vaccine ordering duty to Fiscal Team with input from Vaccine Coordinator
  • Utilize marked vial as template for counting remaining doses during inventory


Overall Improvements

  • Reduced variances between actual inventory and NCIR inventory. These variances over one year had an estimated value of $30,725.25.
  • Developed procedure for training staff and vaccine accountability.
  • Improved team work.
  • Reduction in errors and waste.

Lessons Learned:

  • Tried new clinic rotation schedule to allow consistent staffing of general clinic nurse to eliminate constant learning curve currently present in 2 month/8 month rotations. This did not work due to we have to have all staff cross-trained for back-up for coverage for vacations, sick time, meetings, trainings and other clinics. Limiting the immunization clinic to only three trained nurses limited coverage when the three nurses were not available.



Programs supported by:

BlueCross BlueShield of NC FoundatoinThe Duke Endowment

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