Mount Morningside Hospital in New York City employed lean management techniques to design and operate its Covid-19 vaccination center. This description of its approach could be used by others that are creating vaccination operations.
As world leaders grapple with how to efficiently and safely deliver Covid-19 vaccines to 8 billion people, the task of building vaccine-administration pods will fall to thousands of local hospitals, clinics, and community centers. There will be no “one size fits all” solution to this challenge; core design elements, based on basic principles of continuous improvement (or lean management), offer a roadmap.
Define the Challenge
All lean, or continuous improvement, work begins with some version of defining the problem to be solved. At Mount Sinai Morningside, an urban community hospital in New York City, our journey to create and operationalize a vaccination pod began with the problem statement: We need to vaccinate X number of people per day in Y location with Z resources.
Understand the Current State
Gathering information and understanding the current state is usually the next step in process design. This phase at Mount Sinai Morningside included gathering as many facts as were available. The data inputs included the physical delivery route of the vaccine; the storage capability of our pharmacy; the number of people trained to vaccinate, schedule, and register patients; the number of pharmacists available to reconstitute the drug; the number of doses expected per vial; and the shelf life of reconstituted vaccine.
Based on the expected volume of patients and consideration of the most user-friendly public access, we chose our auditorium as the site to build the vaccination pod. This decision was a critical factor in planning the process steps. Once we settled on the location, “gemba walk” observations could be performed. Gemba, adapted from a Japanese term meaning “the actual place,” describes the place “where value is created.” Gemba observations in our case included the following:
- From the loading dock delivery site to the pharmacy
- From delivery to storage
- From storage to reconstitution
- From the pharmacy to the vaccine pod
- From the front door to the correct elevator
- From the elevator to registration/scheduling
- From the registrar to the waiting area
- From the waiting area to the vaccination bays
- From the bays to the recovery area
- From recovery to exit from the building
Since the processes were not yet built, we conducted our observations using a simulation mindset, asking, “What will it look like?” and considering possible options in the space where those processes would be implemented.
Map the Process
Understanding, at a high level, what steps would be needed to deliver the vaccines, we then brought together a multidisciplinary to team to create a process map using multiple swim lanes, which identified the roles we thought would be needed and showed the steps for which they would be responsible. We specified the scope of our design work and used post-it notes to outline the proposed steps. “Start” was defined as “vaccine arrives at the loading dock,” and “End” was defined as “patient completes recovery time.”
Each step in the process was associated with a different role(s) and we color-coded the functions so that everyone could easily see when each role would participate in the process. In a separate exercise, the entire pharmacy process — from “vaccine arrives in pharmacy” to “vaccine is delivered to the pod” — was outlined with a process map to allow the pharmacy team to visualize potential obstacles, define roles, and plan efficient storage and preparation of the vaccine.
Define the Standard Work
Standard work refers to the steps that must be taken in order to complete a process in the best-known way. It is written by the people who do the work, socialized to all who do the work, and is meant to change when an improvement to the process is made. Some of the roles for which standard work was written were as follows:
The pod manager oversees all pod activity; conducts pod team huddles; performs vaccine count; orders vaccine based on the anticipated schedule; reports to the incident management team; troubleshoots issues as they arise; collects data such as the number of vaccines administered, no-show patients, and vaccines wasted; and so on.
The pharmacist receives, stores, prepares, and delivers vaccine, and coordinates the number of doses to prepare with the pod manager.
The registrar/scheduler schedules and registers patient appointments, abides by state guidelines with regard to adding persons to the schedule; registration for dose #2 is supplemented by registration kiosks to help speed the process.
The vaccinator is a registered nurse, physician’s assistant, nurse practitioner, or physician who administers injections. The vaccinators are trained to use the ambulatory care version of our electronic health record to document the encounter and must have an active New York State license and active basic-life-support certification.
A physician, physician’s assistant or nurse practitioner must be always available in the pod to respond to any medical emergency or to field medical questions.
A navigator helps patients find their way from the front door to the pod, helps maintain social distancing, and assists patients in completing the regulatory registration form while waiting to be registered. We used setup reduction to save time by moving the form completion ahead of the encounter with the registrar.
The screener verifies that persons entering the pod do not have a fever, Covid-19 symptoms, recent contact with someone infected with Covid-19, or a need for quarantine based on their recent travel histories.
The flow master continually monitors the process, looking for and addressing flow obstacles, may add more staff and expand the wait space, and communicates any adjustments to flow with patients and pod staff.
The staff coordinator manages the daily schedules to fill the pod roles.
Multiple dress rehearsals for these roles were conducted. Each simulation led to a greater understanding of the process, revealed more obstacles and challenges, and led to the creation of smoother processes and a more confident staff when the pod was finally opened to real patients.
Simulation of the pod setup led to many design iterations. Patient privacy was addressed by configuring privacy screens into squares that are large enough to accommodate a patient chair, a laptop on wheels, a table to hold supplies such as band aids and alcohol wipes, a sharps container, and a small trash basket. At least one of these bays was made large enough for bariatric patients or for patients in wheelchairs. The simple set up allowed for quick scaling from six to 10 bays as our daily volume increased from 35 injections on Day One to over 700 at peak to date.
Each bay has standard supplies, and a printed set-up diagram is hung in each bay. Given that vaccinators rotate, this made it easy for the people on duty to assemble the space. The diagram helps to minimize the waste of time (delays caused by missing items or excessive items).
By design, our pharmacy delivers 20 syringes by 7 a.m. This is enough to start the day while the pharmacy continues to prepare the remaining doses for the morning shift. We minimize batching by continually checking the remaining patients on the schedule against the pharmacy order for vaccines. The pharmacy and pod manager communicate throughout the day to account for no-shows and to review the remaining number of patients on the appointment roster. As the day progresses, dose production is decreased to remain in sync with the real-time schedule and ensure that no doses will be wasted.
A 6S exercise — organizing the workplace so that supplies are sorted, set in order, standardized, and safely stored — was done before seeing our first patient. This activity included organizing the vaccines themselves. After several iterations, we adopted this approach: receive the vaccines from the pharmacy in sealed bags of 20 syringes labeled with the lot number and the time of expiration. These standard lot sizes make it easier to count the number of syringes received in the pod. The vaccines are stored in a locked cabinet in two bins. One has up to 20 loose syringes, and the second has sealed bags of 20 vaccines — enough for the first shift of vaccination. Both bins are labeled to indicate which syringes should be used first and arranged so that earlier expiration times are first to be used.
Visual management was used extensively to guide patient flow using floor and wall signs, label the bays (1-10 in our case) and to separate areas of the pod (registration, recovery).
Templates were created to document vaccine counts, a critical step in managing the pod. The syringes are counted by the pod manager each time they are received from the pharmacist; both verify the count number and document this in a log. The vaccinators can take three syringes at a time and must sign for them. There are several timeouts during the day to compare the number of doses given with the number of doses remaining in the locked cabinet. Vaccinators must sign out at breaks and at the end of the day, and no syringes are left unattended.
Daily management of the pod begins with a start-of-the-day huddle centered around a daily management board. The huddle script includes identifying the staff in the pod that day; reviewing any change in processes or anticipated flow issues; identifying any supply, equipment or environmental defects; and relaying the anticipated census of patients to be seen. A tiered huddle system allows notable pod information to escalate to the daily morning hospital safety huddle and to the afternoon incident management team huddle.
Efficient flow, excellent patient experience, zero harm, and meticulous stewardship of the vaccines themselves are the goals for any well-run vaccine pod. The enormity of the task, based on both demand and urgency, leaves little room for error. A basic continuous improvement infrastructure provides excellent tools and strategies to quickly design and scale vaccination pods that can be customized to location, size, and available resources.