To assess barriers to implementing standing order protocols (SOP) for vaccinations and influential authorities in making vaccination decisionswith the proportion of black residents, and vaccination coverage in nursing homes. The Centers for Medicare & Medicaid Services and the Centers for Disease Control and Prevention in 2000-2002 surveyed approximately 280 nursing homes in14 states. Data from the On-line Survey and Certification Reporting System were included. A demonstration project to adopt

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... SOPs for vaccination and to assess barriers. Factor analysis and structural equation models were used to assess relationships ofbarriers and influential authorities to implementing SOPs. External facility concerns are barriers to implementing SOPs (p=.031), and nursing homes with higher proportions of black residents are more likely to report those concerns. The medical director and the facility administrator are the most influential authorities determining whether SOPs are implemented. The Quality Improvement Organization (QIO) and the state certification surveyor also played important roles in influencing staff making vaccination decisions. The state's QIO and the state certification surveyor may play important roles in addressingconcerns about staff's authority to vaccinate under SOPs.Barriers external to the nursing home may play a more important role than internal facility barriers.