Operations And Supply Chain Management -
How to Set Up an Efficient Covid-19 Vaccination Site - Sun and Planets Spirituality AYINRIN
A
volunteer disinfects a seat in the post vaccine observation area as
Covid-19 vaccines are administered at the NHS Nightingale North East
hospital on January 26, 2021 in Sunderland, England.
Ian Forsyth/Getty ImagesSummary.
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Summary
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:
Vaccines:
- From the loading dock delivery site to the pharmacy
- From delivery to storage
- From storage to reconstitution
- From the pharmacy to the vaccine pod
Patients:
- 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.
Execution Considerations
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.
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