Background and objective Despite the availability of the pneumococcal vaccine since 1977, the vaccine is greatly underutilised. Centers for Medicare and Medicaid Services, The Joint Commission and Healthy People 2010 have all listed the administration of the pneumococcal vaccine before hospital discharge as a standard of care and a quality initiative in the 21st century. SSM St Mary's Health Center chartered a multidisciplinary team to address a disappointing pneumococcal vaccination rate of 34.7% in the first quarter of 2005.

Methods The team utilised the improvement model of Plan–Do–Study–Act to implement and monitor process changes. Changes were made to four key steps in the pneumococcal vaccination process: assessment, ordering, obtaining and administering. The team also implemented a concurrent review process. The team tracked the hospital's pneumococcal vaccination rate per the published Centers for Medicare and Medicaid Services and The Joint Commission guidelines.

Results Over a 2-year period, the vaccination rate of pneumonia patients has improved incrementally from 34.7% and is now consistently greater than 90%.

Conclusion Utilising Plan–Do–Study–Act allows for continual improvement of the vaccination process. Multiple cycles are necessary to achieve standardisation and optimal process flow.