Should Our Health System Require / Mandate Covid Vaccination for All Staff and Providers?

Many healthcare leaders are asking that question about vaccine requirements or mandates these days. Many of them are saying “yes, we should require vaccination in our healthcare workplaces” and we, at Value Capture, agree with them.  

We strongly support the decision by health system leaders to mandate vaccines. We believe it's important to strive for “Zero Harm” — and requiring vaccination gets us closer to Zero Harm due to preventable cases of Covid, and Zero Harm due to health systems being further overwhelmed by unvaccinated Covid patients.  

Can We Require Vaccination?

The answer to this is also “yes,” at the time of this writing, based on legal rulings that have been made to this point. The requirements must include certain exceptions, as discussed later in the post.  

Houston Methodist was the first, in March, to publicly mandate vaccination of all staff. They required this first for their leaders, then employed staff, and then for their credentialed non-employee physicians (and other types of providers), as seen in this later statement: 

Houston Methodist Requires COVID-19 Vaccine for Credentialed Doctors

Leaders Must Lead by Example

The leaders led by example, by getting vaccinated first, which we greatly appreciate. The leaders showed their confidence in the vaccine and made it clear that they weren’t mandating staff to do something they wouldn’t do.  

As it said in this article from April 9: 

Houston Methodist managers have until April 15 to get at least their first coronavirus vaccine dose and new hires must be vaccinated before they start, according to an email from CEO Marc L. Boom, MD, shared by a spokesperson. The system's next step will be to mandate all 26,000 of its employees and employed physicians to get vaccinated, the spokesperson said. No deadline has been set for them yet.

“We must lead by example and get vaccinated ourselves,” Boom wrote in the March 31 email, noting 95% of managers, all executives, and 83% of employees had already done so. “Show our employees how important getting vaccinated is.”

The EEOC Gives Guidance

The U.S. Equal Employment Opportunity Commission (EEOC) provided guidance on May 28th that said: 

“Federal EEO laws do not prevent an employer from requiring all employees physically entering the workplace to be vaccinated for COVID-19, so long as employers comply with the reasonable accommodation provisions of the ADA and Title VII of the Civil Rights Act of 1964 and other EEO considerations.”

In June, Houston Methodist cited the EEOC in their statement:

“Dr. Solomon [president of the medical staff] adds that Houston Methodist is within not just its legal rights to require vaccination, but also its moral rights. He echoed Houston Methodist President Dr. Marc Boom's admonition that it's Houston Methodist's “sacred obligation to do everything possible to keep our patients safe.”

We agree that it's morally right to require a vaccine that has been proven safe and effective.

The Lawsuit Against Methodist is Thrown Out

On May 28th, a group of Methodist employees filed a lawsuit in opposition to the vaccine requirement, but this suit was dismissed a month later. 

"U.S. District Judge Lynn N. Hughes ruled June 12 that the health system did not violate state or federal law or public policy with its requirement.

“This is not coercion. Methodist is trying to do their business of saving lives without giving them the COVID-19 virus,” Mr. Hughes wrote in the ruling, which was shared with Becker's. “It is a choice made to keep staff, patients and their families safer.”

The lawsuit is currently under appeal.

Methodist personnel were given until June 7th to get vaccinated or face a two-week suspension, facing termination on June 21st.  

153 people were fired or resigned out of 26,000, a total of 0.6%.  

For healthcare leaders who are concerned that a vaccine requirement will lead to a mass exodus (in a time when staffing shortages are already a major concern), those numbers might be reassuring. Keep in mind that Houston is a very competitive market, where those 153 individuals could quite likely find a job someplace else that is not mandating the vaccine. 

More recently, as this article leads with:

“Justice Amy Coney Barrett on Thursday rejected a plea from a group of Indiana University students to stop the university’s requirement that all students be vaccinated against the coronavirus.”

While that lawsuit was against a university (and not a health system), it might predict the legal battles continuing to tip to the side of requiring vaccination.

Other Health Systems (and States) Issue Mandates

Some organizations were pursuing this same path, but others clearly were given a confidence boost by Methodist's mandate and the response from the EEOC and the court ruling. 

California orders vaccination of healthcare workers by Sept. 30

"The order applies to workers in hospitals, skilled nursing facilities, intermediate care facilities, ambulatory surgery centers and in most other healthcare settings. Workers may be exempt from the vaccination requirement if they are granted an exemption for religious beliefs or qualifying medical reasons. Unvaccinated exempt workers must meet testing and safety requirements."

In a blog post, Dr. Eric Dickson, President and Chief Executive Officer and UMass Memorial Health Care, announced mandates: 

COVID-19 Cases Increase; Mandatory Vaccinations for our Caregivers

Listen to our podcast with Dr. Dickson about their response to Covid-19:

Compelling Reasons for Mandating Vaccination

In his post, Dr. Dickson wrote about his efforts at getting a Massachusetts-wide policy enacted:

"The best defense against a third possible COVID-19 surge is to get vaccinated. As Chair of the Massachusetts Health and Hospital Association’s Board of Trustees, I led the approval of a statewide consensus policy to endorse mandatory COVID-19 vaccinations for all Massachusetts hospital and health system employees. Each hospital and health system will establish its own policy and timeline for mandatory vaccinations."

His system will be rolling out the requirement by “fall,” with October 1 and November 1 deadlines for different groups.

The Fairview and Allina systems in Minnesota are also requiring vaccines for employees, at a point when 23% were unvaccinated, saying:

“As a healthcare system and an organization deeply rooted in our community, it’s our responsibility to protect the wellbeing of our teams, to provide a safe and healthy environment for those we serve, and to set an example for our neighbors,” the email states. “Research overwhelmingly shows that getting a flu vaccine and a COVID-19 vaccine dramatically reduces your chances of spreading disease, experiencing severe illness and, potentially, death.”

Their executive comments also cite:

“The American Medical Association and the American Nursing Association, which say increasing infections from the delta variant and vaccine skepticism should lead health care workers to ‘uphold their professional and ethical obligations' and set an example for disease prevention.’”

Here is a helpful, and detailed, article (from April) by the Kaiser Family Foundation: 

Key Questions About COVID-19 Vaccine Mandates 

Do Vaccines Prevent the Spread of Delta Variant of Covid-19?

When the early vaccine requirements were being enacted, there was a strong consensus that the vaccinations not only protected the vaccinated but also dramatically reduced the spread to others. This strengthened the case for requiring vaccination, as getting vaccinated or not goes beyond a personal choice that only affects oneself. 

With the spread of the Delta variant, the CDC put out revised guidance that suggests that Covid can be spread by vaccinated people who have a “breakthrough” case. 

“Our vaccines are working exceptionally well,” [CDC Director] Walensky told CNN’s Wolf Blitzer. “They continue to work well for Delta, with regard to severe illness and death – they prevent it. But what they can’t do anymore is prevent transmission.” 

Even if the Delta variant can still be spread by the vaccinated, there's an increasingly small chance that a vaccinated person gets infected with a previous variant, and the vaccine would prevent them from spreading that — hence a benefit to patients.

Update: This news article shares more about how the vaccinated have a viral load that's the same as the unvaccinated, but the vaccine does reduce the risk of infection to begin with:

“None of the coronavirus vaccines approved for use in the U.S. or U.K. thus far eliminate the risk of infection, but they all reduce that risk by between about 70% and 90% — and they've proven much more potent at preventing hospitalizations and deaths.”

A lowered risk of having infected (and virus shedding) colleagues can be accomplished through increased (if not mandated) vaccination.

It's still possible or likely that the vaccinated are shedding virus for a shorter period of time, says this BMJ article.

"Sarah Walker, professor of medical statistics and epidemiology at the University of Oxford and chief investigator of the survey, said, “We don’t yet know how much transmission can happen from people who get covid-19 after being vaccinated—for example, they may have high levels of virus for shorter periods of time."

Since the infection risk (and risk of shedding virus) isn't zero, that's why we are back to mask mandates in many places because masks do reduce the spread. 

But there's more to consider beyond transmission. The unvaccinated are more likely to breed new variants, which creates risks for others, including the vaccinated.

“The vaccine saves lives,” [Dr. Christina Ghaly, Los Angeles County director of health services] said. “It reduces the risk of infection, it reduces the risk of spreading the virus to others and, critically, in doing so it reduces the risk of those individuals serving as a petri dish, really, in which the virus can continue to mutate into progressively more dangerous forms that put everyone at risk.”

This is confusing, how much vaccination helps protect others, but we keep learning more and will continue to do so.

Update (October 12) -- more is being learned about how being vaccinated may very well protect others. 

Breakthrough COVID may not be as threatening as scientists thought

Requiring Vaccination is Also in the Systems' Best Interests 

If a healthcare organization has a number of unvaccinated staff members, that can contribute to a number of problems that would affect their organization and their community. 

Unvaccinated employees are more likely to get sick with Covid, which means they will (at best) be out of work, hampering the already overstretched organizations that are already seeing a spike inpatient volumes. 

Don't contribute to that spike because (at worst) these healthcare professionals will require rooms, care, ventilators, and other things that are in short supply. Don't get sick and contribute to the staffing problems — getting vaccinated serves those purposes, as it's in the self-interest of the health system to mandate it — and it's a caring gesture toward the employees. 

When unvaccinated employees get sick, the literal cost of care is most likely borne by the healthcare employer that is providing insurance. The average cost of Covid treatment ranges “from $51,000 to $78,000” according to Healthcare Finance, but treatment can cost over $1 million. 

Healthcare organizations in the U.S. have been struggling financially during the pandemic, especially when elective surgeries and other care has to be postponed due to a lack of hospital supplies or capacity that are being consumed by Covid patients (and sometimes postponed by state mandate or request). Less revenue and higher healthcare costs provide an additional burden in healthcare organizations. 

Driven by Principles, Including Respect

Leaders who require vaccination have to realize that some employees will disagree. Some will get upset. Some will quit or file a lawsuit. But leaders need to have to courage to do what's right, taking action based on principles. 

https://valuecapturellc.com/guiding-principles-shingo-model/If we look at the Shingo Principles for Operational Excellence, some of them can be connected to the decision to require vaccination. 

In keeping with the principle of “Respect Every Individual, “we believe leaders need to listen and be respectful when employees voice concerns or disagree with a policy. Leaders can help educate people when their concerns are based on misinformation or outdated information.  

In his post, Dr. Dickson wrote: 

“I recognize that for those who have not been vaccinated, this decision to mandate the vaccine raises concerns. We’ve thoroughly reviewed the science behind the vaccines, are following guidance from the Food and Drug Administration and the Centers for Disease Control and Prevention and feel this is the best way to keep our caregivers and patients safe from this horrible disease that keeps getting stronger. We have the same mission as we did last spring – to save as many lives as possible during this pandemic – and the vaccine is the best way to do that.” 

St. Jude Children's Research Hospital was the first to mandate vaccination in Memphis.

In their announcement, their CEO respectfully addressed hesitancy and was willing to provide information and have conversations about it:

“I understand that some of you have questions and concerns about receiving the COVID-19 vaccine and may be reluctant to do so for various reasons. At St. Jude, we have a team of world-renowned researchers and clinicians who are happy to speak with anyone who is hesitant about receiving the vaccine."

The CEO emphasized the need to protect their patients — children.

More on the Shingo Principles: 

Respect Every Individual: One could argue that “respect” means allowing each person to make their own decision; we would agree, in most aspects of normal daily life.  

But respect, more importantly, means thinking about how your action (or lack of action) affects others.  

That's because we Think Systemically. We are all part of a number of systems — our community, our workplace, etc. None of us stands alone as an island. What we do or don’t do in this moment ripples outward and impacts, positively or negatively, the lives of others.  

We “Embrace Scientific Thinking” and are driven by facts and data, and not false rumors or conspiracies. That's an argument for vaccination. Scientific Thinking means evolving as new information becomes available, which is why, for example, we're now wearing masks even if we are vaccinated. 

Again, when leaders make these announcements, they should Lead With Humility and listen to what their employees are saying, even if they disagree. 

The Courage to Lead

As a final thought, last year we published some collected speeches by the late Paul H. O'Neill, Sr. in a free eBook. 

He said: 

“Take with you the courage to lead. It is the most important thing, that we not wait for someone else to lead.” 

On his behalf, and in his memory, we admire and appreciate those, like Houston Methodist, who made a principled decision even in the face of a then-uncertain legal and regulatory environment.  

We also applaud those who were emboldened by the EEOC and the Methodist lawsuit being dismissed.  

And we applaud those who perhaps moved more slowly, but are also now doing the right things for the right reasons.