Implementing a vaccination mandate: A playbook from 8 hospitals, health systems

Hospitals and health systems across the U.S. began announcing COVID-19 vaccination mandates in March, and the American Hospital Association estimated 42 percent of hospitals had announced a mandate as of Nov. 11. A new CMS Omnibus COVID-19 Health Care Staff Vaccination Interim Final Rule requires vaccination for all eligible staff at healthcare facilities participating in Medicare and Medicaid programs.

Becker's Hospital Review reached out to hospitals and health systems that have implemented COVID-19 vaccination mandates to gain insights into how they have dealt with backlash from the public and their employees; their verification processes for medical and religious exemptions; the steps they are taking for staff members who refuse to comply; and what they are doing to prevent any workforce shortage from the mandate. 

Messaging to staff

Children's Minnesota, an acute care children's hospital system in St. Paul and Minneapolis, announced its vaccination requirement in August. Since then, the system said a comprehensive approach has been taken to reiterate the requirement and provide resources for employees related to the vaccination requirement. That included frequent email reminders, town halls and office hours to answer vaccine-related questions from staff. 

Maria Stuck, executive director of human resources at Oaklawn Hospital in Marshall, Mich., told Becker's the hospital began communicating about the potential for a COVID-19 vaccination mandate months in advance of its decision to implement one in September. The hospital communicated with employees via email, newsletters and in-person meetings that it was considering adding a mandate.

Ms. Stuck said employees had a lot of questions about a mandate, so the hospital created a running list of frequently asked questions and provided answers to them. It sent an updated FAQ document to all staff via email each time there was a change or addition. 

"It was essential to keep the communication lines open and discuss employees' concerns with them," Ms. Stuck said.

At New Hyde Park, N.Y.-based Northwell Health, the health system communicated the upcoming vaccination mandate through town halls, emails and team meetings. It also equipped leaders with resources to engage unvaccinated team members in conversations, conducted question-and-answer sessions and was very open to the media.

Maxine Carrington, chief human resource officer at Northwell, told Becker's that it was vital to keep the messaging positive.

"We kept the message positive, rallying team members about our obligation as a leading healthcare provider that protects and cares for the community," Ms. Carrington said. "In cases where we were unable to convince someone to get vaccinated, we guided everyone to maintain courtesy and dignity and to show respect to protesters."

Jeremy Cauwels, MD, chief physician at Sanford Health, told Becker's the system sent an email to its 48,000 employees announcing the mandate. It initially launched a "robust vaccine education campaign" in December 2020 for employees and the community, which has continued to present day. 

Dr. Cauwels said any employee who has side effects from the vaccination is given paid community leave. 

"As the pandemic continues to take a toll in the communities where we live and work, it's important to remember we're all in this together," Dr. Cauwels said.

Processes for exemptions

Ms. Stuck said Oaklawn Hospital requires documentation for medical exemptions from an employee's provider indicating why they should not be vaccinated for medical reasons. For religious exemptions, any supporting documentation an employee wishes to attach to the exemption request is considered, following guidelines from the U.S. Equal Employment Opportunity Commission. 

Ms. Carrington of Northwell Health said it has centralized teams in place to review all exemption requests. For religious exemptions, the health system uses its employee relations and legal affairs teams to review the request. For medical exemptions, Northwell uses its employee health service and clinical leadership teams.

As Conway (Ark.) Regional Health System introduced its COVID-19 vaccination mandate, officials said they noted more religious exemption requests that cited the use of fetal cell lines to develop and test the vaccines. 

What resulted was a form from Conway for employees requesting religious exemptions to confirm they do not use certain everyday medications, such as Benadryl, Sudafed and Tylenol, in alignment with their sincerely held religious beliefs. 

"We went from two or three religious exemptions a year [for the flu shot] to 45 [for COVID-19 vaccines], which told us something else was going on, and maybe they didn't understand how prevalent fetal cell use is in the testing and development of medicine, common everyday medicine. So, we wanted to make sure that staff were aware how ubiquitous this was, and secondly, to be consistent in their sincerely held belief," Conway President and CEO Matt Troup said during a September interview.

The form lists 30 medications and asks employees to "truthfully acknowledge and affirm that my sincerely held religious belief is consistent and true and I do not use or will use any of the medications listed as examples or any other medication … that has used fetal cell lines in their development and/or testing."   

Few religions outright reject vaccinations, but some religious groups have raised the issue of vaccines being developed and tested on fetal cell lines, which are grown in labs and derived from fetal cells of fetuses aborted decades ago, according to Denver-based 9News, which spoke to James Lawler, MD, an infectious disease expert at the University of Nebraska Medical Center in Omaha.  

"I understand why people have concerns," Dr. Lawler told the news station. "The bottom line is almost all the medical products we use have in some way been touched by research that's been done on fetal cell lines."

Mr. Troup said the purpose of the form is to be educational about medicines and vaccines and for employees to validate that their beliefs are sincerely held. 

Andrew Bindman, MD, executive vice president and chief medical officer at Oakland, Calif.-based Kaiser Permanente, said in a statement shared with Becker's that some employees submitted false requests for religious exemptions. Many employees submitted similar or nearly identical requests containing language taken word for word from online forums, he said. The health system had to conduct a thorough review of all requests for religious exemptions and ensure employee requests reflected sincerely held beliefs. 

"We believe that misusing the religious exemption to avoid vaccination is disrespectful to those with sincere religious beliefs, and could violate the ethical standards we expect our employees to meet," Dr. Bindman said in the statement. "Employees whose exemption requests are denied are put on unpaid administrative leave and provided an opportunity to get vaccinated and return to work."

Kaiser said it is working to educate employees and ease concerns about the vaccines.

Dr. Cauwels said Sanford Health has a system in place to review and provide exemptions for employees with certain medical conditions or who demonstrate a sincerely held religious belief warranting the exemption, in accordance with applicable state and federal law. 

Process for employees who do not comply

Children's Minnesota employees who did not have an exemption and refused to get vaccinated by the deadline received multiple opportunities to comply with the system's vaccination requirement. The system said a small number of employees who refused to comply were terminated.  

At Oaklawn Hospital, employees were required to either have their first dose of a COVID-19 vaccine by Nov. 1 or have their declination approved. Those who did not were separated from employment. Second doses must be complete before Dec. 1, and employment separation will occur for anyone not compliant by then. 

At Northwell Health, Ms. Carrington said unvaccinated team members received multiple alerts about the importance of being vaccinated and a deadline to comply. Those who didn't follow the mandate were "exited from the organization." Ms. Carrington said Northwell is allowing team members who changed their minds and presented proof of vaccination to return to their roles. 

Kaiser Permanente said that as of Oct. 30, more than 93 percent of its employees have been vaccinated. About 1 percent of its active workforce has declined to respond to the vaccination mandate and are on unpaid leave. They have until Dec. 1 to respond by either receiving a vaccine or submitting an authorized exemption request. 

Dr. Cauwels told Becker's Sanford Health employees who did not start their vaccine series or did not receive an approved exemption by Nov. 1 faced suspensions for up to 60 days without pay and were removed from the work schedule. 

"As of today, fewer than 1 percent of employees across Sanford Health have been suspended," Dr. Cauwels said. "We anticipate during this time that employees will make an effort to comply with the policy. However, continued failure to comply with the COVID-19 vaccine requirements within 60 days will result in the employee being considered to have voluntarily resigned from their employment." 

Handling employee pushback

Detroit-based Henry Ford Health System, which employs more than 33,000 people, announced June 29 that it will require workers to be vaccinated as a condition of employment. 

Most employees were considered in compliance because they received their first of a two-dose vaccine or received an approved medical or religious exemption. About 400 employees, however, left the health system over the mandate. 

Amid concerns from some employees, Henry Ford offered daily communications related to vaccination in the health system's internal electronic newsletter and provided information about the science and data behind vaccines, according to a September interview with Bob Riney, president of healthcare operations and COO at Henry Ford.

Other efforts Mr. Riney cited included leaders visiting with individuals who might be hesitant to get vaccinated to learn what their concerns are; holding virtual town halls and employee listening sessions; and considering population segments who might want to hear from people in those same segments. For example, one of the health system's leading African American physicians talked to workers about her own vaccination hesitancy and journey. 

At Atrium Health, staff members who shared their desire to be fully vaccinated close to the Oct. 31 deadline were given extra time to complete the second shot.

"We are recognizing these good faith efforts, and teammates who have received at least one shot are considered on their way to being in compliance with our vaccination policies, as long as they complete their second shot by Nov. 30," a statement emailed to Becker's said. "We anticipate less than 1 percent will not be in compliance by Nov. 30." 

How to deal with potential staffing shortages as a result of a vaccination mandate

Ms. Stuck said Oaklawn Hospital is doing its best to recruit additional staff and working to redeploy current employees to the areas with the greatest need. 

At Northwell Health, leaders were tasked with meeting with unvaccinated team members one on one to understand their intent to get inoculated or not. This allowed for insights into how much staffing would be affected, Ms. Carrington said, adding that its HR department worked with the clinical team to anticipate potential personnel shortages. 

Northwell also activated its staffing agency to provide replacement staffing and relied on an external staffing agency when needed. It also readied its internal reassignment reserve, though it was not used, Ms. Carrington said.


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