By Solveig Dittmann, RN, BA, BSN, CPHRM, CPPS

Despite many months of public and private efforts to make vaccines widely available across the United States, approximately 48% of the general population remains unvaccinated. To date, over 500,000 healthcare workers have contracted coronavirus. Of these, over 3,600 workers have died. As recently as June 2021, it was estimated that one of every four hospital workers with direct patient contact was still unvaccinated. 

Following a period of contraction, the rise of the highly transmissible delta variant in December 2020 has put many healthcare organizations in a similar or even worse situation compared to their circumstances during the pandemic’s peak. 

Many organizations have “reached the breaking point with soft efforts to encourage vaccination” and are considering vaccine mandates. On March 31, 2021, Houston Methodist broke ground by becoming the first major academic medical center to mandate COVID-19 vaccinations for its 26,000 employees. Soon after, it extended the mandate to 7,500 private practice physicians with hospital privileges. In response, 117 employees sued the organization, claiming it could not require a vaccination mandate as a prerequisite for employment. A federal judge dismissed this suit. As of June 28, Houston Methodist’s employee vaccination rate was 99%.

A number of large healthcare organizations have followed Houston Methodist’s example. Not all, however, have gone so far as to terminate employees refusing vaccines. Policies range from those issuing vaccine mandates to those accommodating employees who refuse or have a medical reason to refuse. Mayo Clinic has mandated staff vaccination by September 17, but employees refusing vaccines can keep their jobs if they complete mandatory education modules, receive regular COVID-19 testing, wear face shields in addition to masks, and practice social distancing while on campus.

Now that the Food and Drug Administration (FDA) has approved Pfizer-BioNTech’s COVID-19 Vaccine, more healthcare organizations are considering issuing COVID-19 vaccine mandates. These vaccines remain a key weapon in the fight against the deadliest modern-day pandemic the world has seen. Nevertheless, there are ethical, legal, and practical issues associated with mandates. In the Harvard Business Review, Houston Methodist leadership outlined the seven-step process they used to develop their COVID-19 vaccination policy. The steps are:

1. Establish an ethical framework.
2. Conduct a risk-benefit analysis.
3. Ensure that policies for religious and medical exemptions are consistent with public health guidance and state and local laws.
4. Provide a robust educational campaign.
5. Combat misinformation.
6. Lead by example.
7. Monitor vaccination rates. 

Houston Methodist’s risk-benefit analysis focused primarily on this question: “Do the available vaccines reduce the harm from a COVID-19 infection more than they increase the risk of severe adverse reactions?”

Data from the Centers for Disease Control and Prevention (CDC) and other professional organizations clearly indicate that the answer to the question is “yes.” CDC statistics for long-term care settings indicate that unvaccinated healthcare staff members are far more likely to infect the facility’s residents and their coworkers, thus potentially putting the entire community at risk.

There are other areas to explore in a risk-benefit analysis for mandatory vaccines. Not all organizations can risk losing a percentage of their employees, especially during this time of crisis. So the analysis should also include a process to weigh the benefits of strict vaccine mandates (terminating unvaccinated employees) against the possibility of a healthcare workforce shortage. Consider these questions:
  • What is the current COVID-19 infection rate in the community? 
  • What is the current hospitalization rate? 
  • What percentage of employees are currently vaccinated?
  • What is the employee turnover rate and vacancy rate?
Once these questions are answered and evaluated, consider the following in determining whether to issue a mandate and, if so, what the mandate should include: 
  • Educate staff. Before mandating, provide robust education to employees about the benefits vs. the risks of vaccines. Enhance this education by including information about the FDA’s recent Pfizer vaccine approval.
  • Listen to concerns. Allow employees to voice vaccination concerns, address them with respect, and provide accurate, evidence-based information.
  • Survey the staff. If considering a strict mandate that would bar unvaccinated employees from working, survey employees to determine how many would refuse the vaccine knowing they would lose their job. Weigh this number against the available workforce in the community.
  • Weigh alternatives. Consider a mandate similar to the one Mayo Clinic issued with accommodation for those who refuse, assuming that additional personal protective equipment, such as face shields, will be available even if the delta surge continues or worsens.
  • Consider a partial mandate. Employees with direct patient care responsibilities or who work with especially vulnerable populations, such as immunosuppressed or intensive care patients, may be required to be vaccinated while other staff members may not. Consider whether a mandate is necessary for all or some employees. 
  • Analyze data. Use infection prevention data to establish whether there may have been COVID-19 transmission from your healthcare workers to patients and vice-versa. Use this data to support your decision. 
  • Consult an attorney. State laws vary regarding an employer’s ability to require vaccinations. Consult an attorney when developing your vaccination policy to ensure consistency with evolving state and federal law.
COVID-19 vaccination rates have increased since early August 2021, especially in areas where the delta variant is on the rise. Health system leaders say that many unvaccinated employees are waiting for more evidence about vaccine safety. They are hopeful that the recent Pfizer FDA approval (with hopefully others to follow) will result in an ever higher vaccination rate as hesitant persons accept the fully approved vaccine.

Organizations should weigh risks to their patients, staff, and surrounding communities when considering mandatory COVID-19 vaccinations. But in order to provide quality care, there are also mandate-related workforce implications to consider. No matter what the decision is, healthcare organizations should lead the effort to educate their staff, patients, and communities using evidence-based information that actively corrects misinformation about COVID-19 vaccines and treatments. 

Copyrighted. No legal or medical advice intended. This post includes general risk management guidelines. Such materials are for informational purposes only and may not reflect the most current legal or medical developments. These informational materials are not intended, and must not be taken, as legal or medical advice on any particular set of facts or circumstances.