Prioritizing and implementing HPV vaccination quality improvement programs in healthcare systems: the perspective of quality improvement leaders

ABSTRACT

Human papillomavirus (HPV) vaccination could prevent most of the ~34,000 HPV-attributable cancers diagnosed annually in the US, but uptake remains suboptimal. Healthcare systems are key partners in implementing HPV vaccination quality improvement (QI) programs. To inform future system-level HPV vaccine initiatives, we sought to understand HPV vaccine QI from the perspective of QI program leaders in healthcare systems. We conducted telephone interviews with a multi-state sample of 17 QI leaders in 15 systems. We analyzed data qualitatively via thematic analysis to describe QI leaders’ perspectives on prioritizing and implementing HPV vaccine QI. All QI leaders endorsed HPV vaccination as beneficial, and some had already prioritized increasing uptake to improve adolescent health and meet payor reimbursement standards. Those not prioritizing HPV vaccination cited concerns including the relatively small size of adolescent patient populations, lack of buy-in among providers, and the need to focus on health services perceived as more profitable or urgent. When implementing HPV vaccine QI programs, QI leaders reported key barriers to be the lack of robust data systems and acceptable QI metrics, limited time, and pressures of a fee-for-service clinical environment. Facilitators included automation and standardization in QI efforts and passionate vaccine champions. Almost all QI leaders reported future plans to implement HPV vaccine QI projects. Findings suggest that many healthcare systems are motivated to improve HPV vaccination. However, resistance to guideline-consistent quality metrics, the narrow target of one vaccine in the adolescent patient population, payment structures, and constrained time of providers are key barriers to practice improvements.

KEYWORDS:

• healthcare systems
• HPV vaccination
• quality improvement
• cancer prevention
• primary care

Introduction

Provider-focused interventions are critical to improving human papillomavirus (HPV) vaccination coverage in the United States (US). Widespread HPV vaccination could prevent most of the ~34,000 HPV cancers diagnosed in the US each year, but only about a third (35.5%) of the nation’s adolescents were fully vaccinated by age 13 in 2019.^1–3 This middling level of coverage has likely declined still further due to the COVID-19 pandemic, with HPV vaccine administration having fallen by as much as 75% in the pandemic’s early months.^4–6 A large body of research, including our own, suggests that helping healthcare providers strengthen their communication and prescribing practices is critical to improving HPV vaccination coverage, and may be especially important in reestablishing routine vaccination services in the COVID-19 era.^7–18, Fortunately, recent research has yielded evidence-based interventions, including provider communication training, assessment and feedback, and learning collaborative models that are effective for raising HPV vaccination coverage.^19–26 However, implementing these interventions and supporting busy providers with training and structural improvements in real-world clinical settings remains a challenge.

Healthcare systems are key partners for implementing provider-focused interventions to improve HPV vaccination. Primary care is rapidly consolidating in the US, such that relatively few pediatricians and family physicians work in small private practices; instead, larger, consolidated healthcare systems of multiple practices now predominate.^27–29 Systems are, thus, uniquely positioned to reach providers with interventions to improve HPV vaccination. Furthermore, they often have infrastructure that could support intervention delivery, including staff dedicated to quality improvement (QI) activities and access to vaccination data via electronic health records (EHRs) or state-based immunization information systems (IISs). System leaders may be motivated to improve HPV vaccination, given that vaccine-related quality metrics, such as Healthcare Effectiveness Data and Information Set (HEDIS) measures, are increasingly reported publicly and used by payers to set reimbursement rates.³⁰ A decision made by system leaders to prioritize HPV vaccination QI could have large system-wide impacts that influence the healthcare provided to their entire patient population.

Despite the importance of their role, relatively little is known about system leaders’ perspectives on HPV vaccination. A better understanding of how improving HPV vaccination coverage fits into systems’ larger QI agendas could allow consideration of the design and implementation of evidence-based interventions for use in clinical settings. To address this gap, we conducted a qualitative study with system leaders responsible for designing and implementing QI activities within healthcare systems. Our aims were to understand: 1) reasons HPV vaccine QI is or is not prioritized within healthcare systems; 2) common facilitators and barriers to implementing HPV vaccine QI initiatives; and 3) system leaders’ interest in future HPV vaccine-related QI initiatives. By describing HPV vaccine QI from the perspective of healthcare system leaders, this study seeks to support future partnerships to scale up evidence-based interventions and improve HPV vaccination coverage nationally.

Material and methods

Participants

We conducted semi-structured telephone interviews with QI leaders working in healthcare systems. We defined “QI leaders” as system employees responsible for planning, directing, or implementing activities to improve clinical practice across multiple clinics in the system. Eligible “healthcare systems” were those with multiple practices that delivered primary care to adolescent patients and were owned and operated by the same parent company; we included both pediatric and family medicine practices. We categorized system size in our sample based on the number of practices providing care to adolescent patients, based on participant report: small (20 or fewer practices) or large (more than 20 practices).

We recruited participants using a maximum variation sampling approach³¹ at the system level aimed at capturing a broad range of perspectives. We constructed our purposive sample to include academic and non-academic healthcare systems in different regions of the US, and included both large and small systems. We identified QI leaders within our selected systems by: (1) searching systems’ websites to identify job titles and position descriptions that included the words “quality” or “improvement”; (2) asking initial interviewees for recommendations of others who might offer relevant perspectives; and (3) soliciting recommendations from our professional networks. We interviewed additional leaders in the same system if our first interviewee recommended doing so to get a better understanding of the system’s QI efforts. Our resulting sample consisted of 17 QI leaders working in 15 healthcare systems in seven US states. Participants provided informed consent and were offered $150 gift card incentives.

Data collection

Two trained interviewers (A.L. and B.K.G.) conducted 30- to 60-minute telephone interviews between May 2019 and March 2020 using a semi-structured interview guide. We audio-recorded interviews with consent and transcribed them verbatim. The Institutional Review Board of The University of North Carolina at Chapel Hill determined that the study did not constitute human subjects research because our low-risk, information-gathering interviews involved interviewees speaking in their official capacity as system leaders.

Analysis

We analyzed data using applied thematic analysis.³² In a first, inductive phase, two investigators (B.K.G. and J.H.M.) independently analyzed a subset of the transcripts (n = 3) using open coding to identify overarching topics of discussion. Through an iterative process of coding and comparison of these transcripts, coders refined resulting codes to develop a standardized codebook. In a second, deductive phase, coders used structural coding to independently apply the codebook to the remaining transcripts, using NVivo 12 (QSR International, Melbourne, Australia), resolving coding disagreements throughout the process via discussion. Once structural coding was completed, we generated coding reports, and investigators analyzed the data code-by-code to identify emergent themes and areas of convergence and divergence in QI leaders’ reports. We described these findings thematically, using representative quotations for illustration. Finally, we re-read transcripts to assess the trustworthiness of our themes and to identify “deviant cases,” or dissenting views, that might require additional analysis.

Results

Participant characteristics

The sample consisted of 17 QI leaders in 15 healthcare systems in the US (Table 1). Systems included those categorized as small (7 systems) and large (8 systems). About half of the systems were affiliated with an academic medical center. Participating QI leaders had a wide variety of position titles (Table 2) and described a similarly wide range of responsibilities. Most were physicians (n= 6) or nurses (n= 6). Of the 12 participants who responded about length of time in their QI role, more than half had been in their position for five years or fewer (Table 1).

Table 1. Healthcare system and participant characteristics

	n	(%)
Systems Characteristics (k= 15)
Region
South	7	(47)
Midwest	6	(40)
West	2	(13)
Number of primary care practices serving adolescents
Small (≤20)	7	(47)
Large (≥21)	8	(53)
Number of pediatric providers in system^a
≤20	5	(33)
21–40	3	(20)
≥41	6	(40)
Affiliated with academic medical center
Yes	7	(47)
No	8	(53)
Participant characteristics (n = 17)
Professional training
Physician	7	(41)
Mid-level provider^b	2	(12)
Nurse^c	6	(35)
Other^d	2	(12)
Number of years in QI role^e
<2	3	(25)
2–5	4	(33)
6–10	3	(25)
≥10	2	(17)

^aOne participant did not answer.

^bIncludes nurse practitioner and physician assistant.

^cIncludes registered nurses and licensed practical nurses.

^dIncludes Master of Science in biology degree and medical assistant.

^eFive participants did not answer.

Table 2. QI leader titles (n = 17)^a

Associate Chief Quality Officer	Director of Quality and Patient Safety
Chief Quality Officer	Information Systems Analyst
Clinical Data Analyst	Medical Director
Clinical Implementation Coach	Medical Director for Performance Excellence
Clinical Quality Project Manager	Nursing Service Manager
Co-director of Pediatric Population Health Initiative	Patient Service Manager
Director of Adolescent Management	Pediatrician (no official QI title)
Director of Clinical Compliance	Pediatric Infectious Disease Specialist
Director of Clinical Services	Vice Chief for Innovation and Strategy
Director of Clinical Quality

^aTwo participants reported more than one professional title.

Prioritizing HPV vaccine QI

All QI leaders described having some role in setting QI priorities for their systems, although the extent to which they maintained formal strategic plans varied. When considering HPV vaccination as a QI priority, QI leaders reported balancing the needs of patients, providers, and the system.

Theme 1.1: At the patient level, QI leaders sought to focus QI efforts on health services that they perceived as simultaneously needing improvement and having meaningful impact on population health

QI leaders were generally supportive of HPV vaccination as being beneficial to adolescent health. Several noted that increasing coverage would translate into better quality care and improved health outcomes in the long term. Furthermore, most felt that HPV vaccination coverage in their system was too low, and even leaders who reported that their system had high coverage saw room for improvement. For these reasons, QI leaders endorsed the idea of HPV vaccine QI as a being potentially worthwhile pursuit, and indeed, QI leaders in 13 systems reported having already led some type of QI initiative to improve HPV vaccine uptake.

Despite this general support, several QI leaders reported that HPV vaccine QI was nevertheless difficult to prioritize relative to other health services given its narrow application to adolescent preventive care. These QI leaders perceived their adolescent patient populations as being too small to justify system-wide HPV vaccine QI efforts or to motivate providers to focus on a single vaccine:

Our general belief is that when we roll something out for a clinician—especially if you’re a general pediatrician, and you have 15 patients in a half day, and you have like one teen maybe, or two at most—it’s hard to roll something out that’s not only specific to a minority in terms of numbers of patients, but also something that’s as specific as a specific immunization. (#5, Physician)

From the perspective of these participants, financial resources and time were better directed to health services that affected larger patient populations (e.g., adult primary care) or to health concerns that were deemed as being more immediate (e.g., chronic disease management) or of the moment (e.g., trauma-informed care). In these ways, QI leaders’ general support for HPV vaccination was not always enough to prioritize it over the many other concerns their systems were facing.

Theme 1.2: At the provider level, QI leaders cited lack of buy-in from frontline providers as a key barrier to prioritizing HPV vaccine QI

QI leaders emphasized that the success of QI efforts depended on the willingness of providers to participate, and in the case of HPV vaccine QI, some perceived buy-in as lacking. QI leaders noted that providers are responsible for many competing clinical tasks, which must be completed in the context of very limited time with patients. They reported that some providers were reluctant to engage in HPV vaccine QI because they perceived HPV vaccination as being a challenge that required time-consuming conversations with parents.

Just getting uptick from the providers, letting them know that it’s not a heavy lift. We have so many competing priorities, … so it’s hard to figure out how to get people interested even when something’s really simple. (#16, Physician)

Furthermore, some QI leaders reported that providers did not view HPV vaccination rates as being changeable; if parents refuse vaccination, providers felt like they won’t be able to change their minds. QI leaders perceived such lack of provider buy-in as a common and serious barrier to HPV vaccine QI, although several noted that it was not necessarily insurmountable. These participants advised that engaging providers in the planning phase of QI initiatives was one way to facilitate buy-in and build support for HPV vaccine QI over time.

Theme 1.3: At the system level, QI leaders reported prioritizing health services that had the potential to bring value to the system, either through increased profit or prestige

Some QI leaders noted financial reasons for prioritizing HPV vaccine QI. For example, more than half of participants said that their system’s QI priorities were set at least partially based on reimbursement standards used by payors such as commercial insurance companies, Medicare, or Medicaid. In the pediatric space, some payors used metrics, including the National Committee for Quality Assurance’s HEDIS measure, to financially reward systems with higher percentages of patients completing the HPV vaccine series and other vaccines in the adolescent platform before age 13.³⁰ QI leaders perceived increased reimbursement to be a highly motivating reason to prioritize HPV vaccination, while also noting that meeting the HEDIS metric age 13 threshold was challenging.

Other QI leaders noted that public reporting of HPV vaccination coverage was similarly motivating. For example, one participant whose system participated in a voluntary quality collaborative that publicly reported HPV vaccination coverage said:

Well, [public reporting] certainly motivated [our system] because now you can see how we compare with local competitors as well as statewide. … consumers are going and looking and seeing how [systems] are doing … they have that data. So, it does incentivize us to make improvements there. Absolutely. (#15, Nurse)

In the case of public reporting, QI leaders noted that both opportunity for increased revenue by attracting patients and prestige in being perceived as a top-performing system could motivate HPV vaccine QI.

In contrast to these reports, other QI leaders found financial reasons not to prioritize HPV vaccine QI, given that systems may not reap the benefit of the HPV cancers they prevent through vaccination. One QI leader who noted an overall reluctance to focus QI priorities on preventive care explained:

If you invest in the preventive care of a patient, you don’t really know if they’re going to be part of your value-based population five or ten years from now when that strategy pays off. And so that’s definitely a challenge. (#1, Physician)

Thus, HPV vaccine QI could be de-prioritized because it was viewed as having no short-term benefits in terms of cost savings to the system.

Implementing HPV vaccine QI

QI leaders discussed barriers and facilitators to implementing HPV vaccine QI, emphasizing that these occurred at the patient, provider, and systems levels.

Theme 2.1: QI leaders reported that many providers felt that they did not have time to focus on HPV vaccine QI, either for required QI training or during patient visits

As with efforts to prioritize HPV vaccine QI noted earlier, QI leaders reported that time limitations were also a barrier to implementing HPV vaccine QI. Participants noted that QI initiatives were often seen as being at odds with systems’ goal of maximizing time spent on patient care to generate “relative value units” (RVUs) that would translate into revenue for systems and, in some cases, financial bonuses for providers. Tasks required for HPV QI initiatives reduced valuable time spent with revenue-generating patient encounters:

It’s the fee for service environment. When you take time to work on [a QI project], you are not producing RVUs and income. And we … can try to pretend that doesn’t matter, but it does. (#1, Physician)

QI leaders explained that implementing HPV vaccine QI could be challenging to the extent that such initiatives required providers to spend time in training or on other non-care-related responsibilities.

Furthermore, some QI leaders encountered the concern that changing prescribing practices for adolescent vaccination could make adolescent visits last longer, especially visits for acute services.

[A barrier is] providers not necessarily feeling that immunizing on demand is going to be worth the extra time when they’re already running behind and they already have patients coming up. (#12, Mid-level provider)

In response to these concerns, QI leaders noted that successfully implementing HPV vaccine QI initiatives required careful attention to minimize the amount of provider time required, as well as providers’ perceptions of the time required. Some systems used non-evidence-based but creative strategies designed to save providers time during patient encounters, including hanging informational posters in waiting and patient rooms with the recommended HPV vaccine schedule as a way of priming parents and patients to expect HPV vaccination offers at certain visits.

Theme 2.2: QI leaders engaged providers’ competitiveness to encourage HPV vaccine QI goals, while incentives remained a largely untapped motivational resource

QI leaders reported that competition worked to inspire providers to focus on improving HPV vaccination coverage at the individual and clinic level. For example, some QI leaders found that using dashboards or scorecards to report and compare HPV vaccine coverage was motivating:

No one wants to be a poor performer, and everyone wants to be the best. So we can use the scorecards to spur individual provider change … [so that providers will say], ‘Okay, it’s worth it for me to do this extra two-minute conversation to go ahead and grab that HPV vaccine while I have that kid here for this ingrown toenail removal.’ (#12, Mid-level provider)

Thus, QI leaders viewed competition as a key facilitator.

QI leaders reported that they rarely used incentives to motivate HPV vaccine QI, despite using a wide range of incentives to encourage providers to participate in QI initiatives for other topics. For HPV vaccine QI, incentives were typically limited to offering maintenance of certification (MOC) or continuing medical education (CME) credit, but these credits were not tied to outcomes. In contrast, many QI leaders did report offering incentives for QI projects related to other health services (e.g., influenza vaccinations), including small rewards (e.g., gift cards), financial rewards (e.g., physician bonuses), system-wide social recognition, or other creative awards (e.g., improvements to the break room). As in Theme 1.1, some QI leaders reported that HPV vaccination was too narrow a target for dedication of incentive resources.

Theme 2.3: Key personnel, including vaccine champions and QI leaders themselves, were important facilitators of HPV vaccine QI

QI leaders observed that it was important to empower providers to carry out HPV vaccine QI initiatives, using system-level support or engaging vaccine champions to answer provider questions and help ease concerns about talking to parents. QI leaders considered vaccine champions to be especially valuable to HPV vaccine QI initiatives. QI leaders described champions as providing education for providers and working to foster enthusiasm for HPV vaccination. According to QI leaders, champions were passionate about vaccination, and were well-respected and well-liked by their peers. Champions often had excellent vaccination rates themselves, which gave them credibility and allowed them to be perceived by other providers as experts.

[S]omeone who is good at convincing patients oftentimes would be good at selling it to other physicians as well …. (#13, Physician)

A few QI leaders noted that it was important that the champion be a volunteer rather than an assigned role to ensure that they were perceived as truly passionate and invested in improving HPV vaccination.

Perhaps not surprisingly, QI leaders also perceived themselves as playing an important role in facilitating HPV vaccine QI projects, although their level of influence varied. QI leaders reported working with providers to ensure understanding of QI goals and aided in both tracking metrics and assessment and feedback. Notably, some QI leaders reported that their success was tied to being perceived as insiders to the providers. Providers were more receptive to QI leaders whom they perceived as having a thorough understanding of the clinical environment, rather than just existing in the corporate structure of the system. This understanding of the clinical environment was achieved by either being a clinician themselves, or by working with providers to determine QI goals so that providers were included in the process.

I think really what helps in this position is having that clinical experience and knowing what the provider and the clinical staff go through on a day-to-day basis and what they do, … and just the workflow, so we’re able to help kind of navigate and streamline things in a better way for the clinic. (#3, Nurse)

Having clinical experience also helped QI leaders understand how QI efforts proposed by non-clinical system leaders might actually work at the provider level, and enabled them to guide QI plans.

Theme 2.4: Systems’ challenges measuring HPV vaccine coverage accurately and in a guideline-consistent way was a significant barrier to implementing QI

QI leaders described using a wide range of processes and data sources for assessing HPV vaccine coverage in their systems; some pulling data from their own EHRs and others relying on their state immunization registries. Reported barriers included poor data quality, difficulty accessing vaccination coverage, and the inability to assess HPV vaccine coverage separately from other adolescent vaccines. Furthermore, HPV vaccine coverage data were often unavailable at the individual provider level. These data problems limited QI leaders’ ability to make use of assessment and feedback, a common strategy for vaccination QI, while also hindering efforts to evaluate QI programs’ success. One QI leader reported that most providers simply assume they’re doing a good job with HPV vaccination if their individual rates are not available.

In addition to limitations with data systems, QI leaders also expressed dissatisfaction with metrics commonly used to assess HPV vaccination. Some QI leaders reported that providers in their systems felt especially frustrated by the HEDIS measure because they viewed vaccination prior to age 13 as difficult and unreasonably strict.

[Providers in our system] think the [HEDIS] deadline’s too early. … So they think that we should not only look at the 13-year-old completion rate, but [also] look at [the completion rate at age] 14, 15. (#9, Nurse)

This view motivated some systems to assess HPV vaccine coverage at older ages, in contrast to national practice guidelines.

Theme 2.5: Automation and standardization within clinics and across systems improved HPV vaccine QI efforts and lessened the burden on individual providers

In keeping with QI leaders’ desire to minimize provider burden, strategies that made HPV vaccine QI efficient, automatic, and simple for providers were thought to be most successful. QI leaders perceived EHRs to be an important component of automation and standardization in HPV vaccine QI initiatives. Systems leveraged EHRs to automatically alert providers when patients were due for the vaccine and to employ standing orders for HPV vaccine when appropriate. One system set EHR prompts to begin alerting providers that a child was due for HPV vaccine when a patient turned nine years old. Several systems had provider-facing dashboards to track progress over time at clinic or provider level. A few systems used automated reminder recall messaging for parents, to alert them when their child was due for the second HPV vaccination.

QI leaders also noted the importance of standardizing resources and QI guidelines across the system. Without coordination, clinics throughout the system were not consistent in their practices or approach to HPV QI initiatives. As one QI leader observed:

I think that’s really been our issue from a quality standpoint. [T]here just hasn’t been coordination and it’s shocking how often people are doing something in one venue, and literally across the street nobody’s doing anything, and yet it’s sort of all technically under one umbrella. (#5, Physician)

Participants remarked that while systems should ensure that they work with clinics and providers to develop QI goals and initiatives from the ground up, coordination of HPV vaccine QI from the top down was an important facilitator to ensure success of the initiative.

Planning future HPV vaccine QI efforts

Theme 3.1: Most QI leaders reported plans for future HPV vaccine QI efforts

Despite the barriers they discussed, almost all QI leaders had future plans to improve HPV vaccination. Plans included using specific metrics to track HPV vaccination, sending reports or scorecards to providers and clinics, or direct outreach to parents with children not up to date. Some participants said their system planned on focusing on provider education to help with conversations with hesitant parents, or offering an MOC credit program. One system planned to offer HPV vaccination at age nine as standard practice, to potentially avoid some parental hesitancy and allow for more time to complete the series before age 13.

When asked if their systems might consider external support for future HPV vaccine QI efforts, QI leaders were split. Some thought that any efforts would remain internal and that their system would be to rely on building on their own QI efforts. Other QI leaders reported that their system may consider outside support if all materials and guidance had already been developed and were evidence-based.

I think we are very receptive, particularly in not reinventing the wheel. Because it just makes sense that if folks have an opportunity or a training or a program that fits, we typically are willing to commit the resources and create an opportunity to improve our outcomes. (#17, Mid-level provider)

Outside support for HPV vaccine QI initiatives was welcomed by QI leaders eager to improve their coverage and looking for an intervention that was already established and demonstrated to be effective. We present additional quotations to illustrate each theme in Table 3.

Table 3. Illustrative quotations for each theme

Theme	Quotation	QI leader # and professional training
1.1. At the patient level, QI leaders sought to focus QI efforts on health services that they perceived as simultaneously needing improvement and having meaningful impact on population health.	[HPV vaccine outreach is] something that’s absolutely very possible [within our existing reminder/recall system]. That would kind of be a no-additional-effort item. But like I said, [HPV vaccination is] so specific that it’s hard to justify.	6, Other^a
1.2. At the provider level, QI leaders cited lack of buy-in from frontline providers as a key barrier to prioritizing HPV vaccine QI.	I think [evidence and scripting] are really helpful to get docs to break open that conversation because it’s not easy and we’re stressed for time. So, it’s easy to let things that are a little uncomfortable fall to the wayside.	1, Physician
	Sometimes it’s hard to get buy-in from clinics that haven’t really had a lot of experience with [QI]. A lot of times they feel like, “Oh, it’s just one more thing they’re asking me to do to run this report.” And trying to win that relationship over with the clinics is really the hardest piece. Once they realize that we’re there to help and we can help that’s when they start saying, “Oh, okay. I can use you. You do have value. Come help me with these things.”	3, Nurse^b
1.3. At the system level, QI leaders reported prioritizing health services that had the potential to bring value to the system, either through increased profit or prestige.	Because there’s so many competing priorities where we have a lot of money at stake I don’t think [HPV vaccine QI] would be as high-priority as you or I might think it should be. … Prevention is so important, but it still hasn’t made it to the top tier [of priorities in our system].	8, Nurse
2.1. QI leaders reported that many providers felt that they did not have time to focus on HPV vaccine QI, either for required QI training or during patient visits.	But I’ll be honest, [QI] gets frustrating at times because the [state health quality collaborative has] so many different metrics that they’re following. It feels like Whac-A-Mole at times. Some [metric] goes bad. You try to fix that, and then something else goes bad. You’re jumping around constantly.	7, Physician
	Time is an issue – making sure someone has adequate time to really do the work that’s required for [HPV vaccine QI]. It’s challenging in our organization because you can imagine if we have a hundred different quality initiatives (which we really do), you can’t make a champion for every single one of them. … I think that’s really the big one – time that takes people out of clinic when we’re so strapped usually for access.	13, Physician
2.2. QI leaders engaged providers’ competitiveness to encourage HPV vaccine QI goals, while incentives remained a largely untapped motivational resource.	The other thing that we’re hoping to leverage with our dashboard is that we physicians like to think that we’re all better than average, even though that’s mathematically impossible. When you see how you’re performing relative to your peers, there’s the sense of competition that kicks in and that internal drive to be better than your peers.	14, Physician
	[Currently], you just get CME credit [for doing HPV vaccine QI], but if I was told I was going to get paid on my HPV immunization rates, on a value care basis, that might incentivize me.	16, Physician
2.3. Key personnel, including vaccine champions and QI leaders themselves, were important facilitators of HPV vaccine QI.	[Providers] know best what the pebble in their shoe is and how their work gets disrupted. We really want them to be owners and both raise the issues but then come up with some suggestions and be able to work on it. [Provider involvement in QI] should increase their engagement and increase our efficiencies and give us a better outcome for our patients and for our staff.	2, Nurse
	I think really what helps in this position is having that clinical experience and knowing what the provider and the clinical staff go through on a day-to-day basis, and what they do, … and just the workflow, so we’re able to help navigate and streamline things in a better way for the clinic.	3, Nurse
2.4. Systems’ challenges measuring HPV vaccine coverage accurately and in a guideline-consistent way was a significant barrier to implementing QI.	[In] pediatrics I think we’ve struggled to really establish pristine, non-controversial metrics to then go with a bundle of ideas to a particular practice to make change.	5, Physician
2.5. Automation and standardization within clinics and across systems improved HPV vaccine QI efforts and lessened the burden on individual providers.	[We make] sure that we have standing orders in for clinical staff or MAs so that, if the patient is in for a lab-only visit or while they’re here for their flu shot, we definitely [check their HPV vaccine status]. If [patients] can get their HPV as well while they’re getting their flu shot … let’s get it done so that [clinical staff and MAs are] empowered to do that. … I think it’s helpful for everyone to assess immunization status at the beginning of every visit.	4, Other
	[Another] key to success is we standardize our immunization schedule. … We found it really reduces our staff confusion because before [some providers recommended vaccination at different ages]. … Once we had a standard message, different staff and the medical assistants know exactly what we’re doing. … They don’t have to remember based on which provider they’re working for. It really made the staff a lot happier, [and] we have a lovely poster that is 18 × 24 inches in every exam room that describes the vaccine schedule.	16, Physician
3.1. Most QI leaders reported plans for future HPV vaccine QI efforts	[W]e have multiple different plans in place. Basically [leaders] pretty high up in the organization who are part of the [National] HPV [Vaccination] Roundtable, they both decided to start focusing on [HPV vaccine]. … And we came up with our own kind of strategic plan for HPV currently that we’re working on from a bunch of different angles.	13, Physician

^aIncludes Master of Science in biology degree and medical assistant; ^bIncludes registered nurses and licensed practical nurses.

Discussion

In this qualitative study, QI leaders in healthcare systems described HPV vaccine QI as existing in a complex environment in which many quality metrics, financial considerations, and stakeholder interests competed for their attention. We found that QI leaders generally valued HPV vaccination as a health service that could benefit adolescent health. By the same token, they were willing to prioritize HPV vaccine QI to the extent that they perceived such efforts as benefitting a sufficiently large patient population, garnering acceptance from frontline providers, increasing revenue, and enhancing their system’s reputation for high quality care. Despite this general support, QI leaders identified barriers that discouraged them from prioritizing, implementing, or incentivizing HPV vaccine QI. These barriers most notably included the perceived “narrowness” of the population impact of HPV vaccination, financial costs associated with HPV vaccine QI, and the absence of acceptable, easily-available metrics to assess HPV vaccination coverage. Understanding QI leaders’ perspectives on these barriers may be instructive to researchers, health departments, advocacy organizations, and others who seek to partner with healthcare systems to implement evidence-based strategies to improve HPV vaccination.

The characterization of HPV vaccination as a “narrow” concern was an undercurrent across our interviews. QI leaders explained that this evaluation was based on the relatively small size of adolescent versus adult patient populations, as well as the perception of lower urgency for preventive versus chronic or acute care. To address this concern, future interventionists should explore opportunities to bundle HPV vaccine with other health services; interventions addressing multiple concerns in adolescent health, including HPV vaccination, that leverage economies of scale across a system may be more acceptable to healthcare leaders. Our findings also suggest the need for continued outreach by Centers for Disease Control and Prevention (CDC), American Cancer Society (ACS), the National HPV Vaccination Roundtable, the American Academy of Pediatrics (AAP), and others to maintain the visibility of HPV vaccination as a national cancer prevention priority.

Not surprisingly, QI leaders were also highly concerned with the financial impact of HPV vaccine QI, noting a tension between the financial benefits of improving HPV vaccine coverage and the costs of doing so. QI leaders reported that financial benefits could include increased reimbursement by third-party payors,³³ and the opportunity to build a reputation for clinical excellence that could attract greater market share. However, potential benefits had to be balanced against the up-front cost to the healthcare system in terms of provider time – and, in turn, revenue – that might be redirected from patient care to conduct QI activities. Though pediatric providers are accustomed to viewing patient care from a life course perspective, prevention can sometimes be crowded out by more immediate needs, particularly in the context of the high-volume practices which many QI leaders in our sample described. Such concerns suggest that in designing interventions every effort must be made to minimize demand on provider time, with time-saving strategies, such as using presumptive recommendations or standing orders that engage nurses and other healthcare team members, being especially promising.³⁴ Emphasizing short-term endpoints in QI (such as reducing HPV infections and anogenital warts in adolescent populations,³⁵ streamlining patient visits, and decreasing expenditures spent on follow up), along with the long-term endpoint of cancer prevention, may help frame prevention as more relevant to pediatric practices. Our findings also suggest promise for value-based insurance designs that reward systems with higher HPV vaccination coverage, as well as public reporting to motivate systems to increase HPV vaccine coverage to improve their reputation for quality and attract new patients. Finally, future research should examine the effectiveness of providing financial incentives to providers, a strategy that QI leaders reported commonly using to improve the delivery of other health services, but not HPV vaccination. Such an incentive might help generate the buy in among providers that some QI leaders perceived as hindering HPV vaccine QI efforts.

Consistent with prior studies, our findings suggest that the lack of high-quality vaccination data continues to be a substantial barrier to HPV vaccine QI,³⁶ along with resistance to using guideline-consistent quality metrics. Most notably, some QI leaders criticized the HEDIS measure, that assesses HPV vaccination before age 13, as being too strict, and some reported using later ages to assess coverage as a result. Using such “late” metrics is problematic insofar as it can support the impression that some providers already have that there is not a specific guideline for HPV vaccine timeliness.³⁷ Many QI leaders expressed interest in outside support for HPV vaccine QI initiatives, and, our findings suggest that data support could be particularly helpful for making the case for “on-time” quality metrics and supporting systems in streamlining and standardizing measurement of HPV vaccine coverage.

We found that nearly all QI leaders had future plans to engage in HPV vaccine QI, despite the barriers they noted. Interventionists planning to work with systems to support HPV vaccine QI should prioritize efforts to build capacity within systems, perhaps providing data support, mentioned above, or providing evidence-based interventions to vaccine champions using a train-the-trainer approach. Partnering with QI leaders is key for outside entities to gain support for HPV vaccine QI in systems and to ensure a standardized approach across a system. However, identifying these QI leaders can be difficult. We noted the wide variety of titles and even responsibilities of QI leaders; finding a QI leader with firsthand knowledge of the clinical environment may help convince providers that HPV vaccine QI initiatives proposed are realistic and doable. Implementation of interventions across systems can be facilitated by ensuring paid time for provider engagement in QI efforts and minimizing time spent on non-clinical QI activities. Interventionists aiming to work with QI leaders can use several promising interventions to promote HPV vaccine QI across systems. For example, the ACS, with support from the CDC, has developed the HPV Vaccinate Adolescents against Cancers (VACS) program,³⁸ which has increased HPV vaccination initiation rates in Federally Qualified Health Centers (FQHCs) and supported the use of standing orders.^39,40 The National HPV Vaccination Roundtable has also developed toolkits for working with healthcare systems.⁴¹

Our study has several strengths, including its focus on healthcare system QI leaders as a highly influential, but understudied group of stakeholders in HPV vaccine QI. Importantly, we engaged a geographically-diverse sample, including QI leaders from academic and non-academic systems. Our study also has limitations. First, our exclusive focus on QI leaders allowed us to explore the perspective of stakeholders with an emerging and important role. However, we acknowledge that many other perspectives are also important to HPV vaccine QI efforts, including those of vaccine champions, frontline providers, and other system leaders. Second, our maximum variation sampling approach achieved our study’s goal to capture the views of leaders from a range of systems, but qualitative analyses such as ours cannot assess the prevalence of these views. We additionally note the variation of US healthcare systems in terms of infrastructure, control, expansion speed, geographic range, and more. As systems quickly dominate the healthcare landscape, future research should examine the impact of system-level characteristics on the implementation of QI activities. Finally, our data were collected prior to the COVID-19 pandemic, which has introduced new challenges to HPV vaccine QI.⁴²

In conclusion, the perspective of QI leaders in healthcare systems is especially valuable as rapid consolidation has led to systems with diverse patient populations of which adolescent visits represent a very small slice. Implementing evidence-based HPV vaccine QI interventions will increasingly require working with QI leaders in systems, rather than standalone practices. Engaging QI leaders provides the opportunity to gain valuable partners in HPV vaccine QI and improve an otherwise disjointed approach to HPV vaccine delivery. Prioritizing and implementing HPV vaccine QI in healthcare systems can support the provision of consistent, high-quality care for adolescent patients, while helping providers and systems meet both patient care and financial goals.

Authors’ contributions

BKG acquired, analyzed, and interpreted the data; and wrote, reviewed, and critically revised the manuscript; JHM conceptualized and designed the study; designed the data collection instruments; analyzed and interpreted the data; and wrote, reviewed, and critically revised the manuscript; AL acquired the data; and reviewed and critically revised the manuscript; MAM wrote, reviewed, and critically revised the manuscript; EDC interpreted findings and reviewed and critically revised the manuscript; MBG conceptualized and designed the study; designed the data collection instruments; interpreted the data; wrote, reviewed, and critically revised the manuscript and supervised the study. All authors approved the final manuscript as submitted.

Disclosure of potential conflicts of interest

No potential conflicts of interest were disclosed.

Ethics approval and consent to participate

This submission was reviewed by the UNC Office of Human Research Ethics (IRB number: 19-1016), which has determined that this submission does not constitute human subjects research as defined under federal regulations [45 CFR 46.102 (d or f) and 21 CFR 56.102(c)(e)(l)]. Consent was obtained by all participants to participate in this research, and no identifiable details related to an individual person are included in the manuscript.

Additional information

Funding

This work was supported by Lineberger Comprehensive Cancer Center Developmental Grant and the National Cancer Institute [R21 CA241518]. Authors Brigid Grabert and Marjorie Margolis were funded by the Cancer Control Education Program at UNC Lineberger Comprehensive Cancer Center [T32CA057726-28]. Funders played no role in study design, collection, analysis and interpretation of the data, in writing the report, or in the decision to submit the article for publication.