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Lean Vaccination of Our Nation

The views expressed are those of the author and do not necessarily reflect the views of ASPA as an organization.

By Kate McGovern
February 10, 2021

As our country struggles with the logistics of administering hundreds of millions of COVID-19 vaccine doses, we are witnessing the principle of continuous improvement being applied in real time. It is useful to begin our discussion with the underlying concept of Lean process improvement. First developed in manufacturing, Lean focuses on customer value: don’t just do it fast, do it right. The core tenet of Lean integrates efficiency with quality. The mission to vaccinate the majority of the American people requires that duality.

Efficiency indicators include:

  • Vaccinate as many people as quickly as possible.
  • Use every dose available.
  • Get ahead of the mutations.

Quality indicators include:

  • Provide a 15–30-minute post-vaccination observation period.
  • Assure efficacy by scheduling a second dose as appropriate.
  • Prioritize frontline medical workers and congregate living residents and workers in congregate living facilities, then others prioritized by medical vulnerability, age and occupation.
  • Assure access for racial and ethnic groups experiencing disproportionate mortality rates.
  • Address vaccine hesitancy.

The obstacles are many. Reliance on each state to construct its own distribution plan had the un-Lean consequence of rework, wasting time and resources. The nonstandard approach caused confusion for the public and for those responsible for carrying out the mission. State and local health departments struggled as the virus surged, with thousands of fatalities each week. As Dr. Ashish Jha explained, “We’ve taken the people with the least amount of resources and capacity and asked them to do the hardest part of the vaccination—which is actually getting the vaccines administered into people’s arms.”

The good news is that the Plan-Do-Study Act (PDSA) principle of continuous improvement is underway, identifying problems and adjusting accordingly.

Establish standard work: Federal coordination and transparency will allow consistent strategies to be applied for jurisdictions with similar circumstances.

Don’t build the process for outliers: Keep it simple. Avoid making intricate rules that attempt to anticipate every scenario. Complexity impedes smooth flow.

Establish smooth flow: Predictable shipment schedules will drive reliable results. Unpredictable vaccine delivery causes chaos. Appointments must be cancelled if shipments fail to arrive as expected. Service is delayed if appointments are not made until after receipt.

Study what works and replicate it: West Virginia consistently led the states in administering its allotted shipments. Jeffrey Zients, the new COVID-19 response coordinator, took notice. One of his first actions was to place a call to West Virginia Governor Jim Justice to find out what lessons could be applied elsewhere. As of February 4, more than 10% of the population in Utah, Alaska, West Virginia, New Mexico, Connecticut and North Dakota had received the first dose of the vaccine. North Dakota and West Virginia had administered more than 80% of their available doses. What strategies used here can be replicated elsewhere?

Utilize Existing Expertise:

  • Allow retired physicians and nurses to administer shots and allow licensed physicians and nurses to administer shots across state lines.
  • Use the National Guard for logistics and for administering vaccines. As of January 21, 2021, states will be reimbursed 100% for the deployment of National Guard. West Virginia Guard spokesperson Holli Nelson explained, “We are a logistical operation here. That is what the military does best.” Lt. Col. Matt DeVivo of the North Carolina Guard reported that they are ready to, “Stick, plunge and pull.” In Maryland, National Guard members were deployed to help with pop-up sites in multiple counties.

Kata: Experiment and apply scientific thinking. As I mentioned in a previous column, Kata is a structured problem-solving technique developed by researcher Mike Rother. Kata combines the scientific process of inquiry with routines of deliberative practice. The methodology is built to incorporate new learning and to adjust accordingly. For example, the federal government plans to ship vaccine directly to pharmacies to augment existing efforts. Will it be more efficient, in keeping with the Lean principle of minimizing handoffs? If so, what else can be learned that will make it even better?

Faster and better. The ethical imperative of reaching vulnerable populations must be linked to efficiency goals. Lives are at risk every day. Black residents of Washington D.C. make up 46% of the population and 74% of deaths from COVID-19. From November to January, the death rate of Latino residents in LA County increased from 3.5 per 100,000 to 40 per 100,000, an increase of more than 1,000%. Effective methods to reach at-risk communities must be identified, replicated, and immediately scaled-up.

Adjust based on changing conditions and new data. The most important part of the PDSA cycle is Act/Adjust. As new variants of the virus emerge, strategies must meet the challenge. Federally staffed mass vaccination sites are opening near the hard-hit communities in Oakland and Los Angles. Tapping state and local partnerships, sites will be set up at stadiums, school gyms and parking lots throughout the country. We are witnessing the urgent value of continuous improvement.


Author: Kate McGovern, MPA, Ph.D. is a Lean trainer and practitioner in the public sector. Formerly a professor for the State of NH, Kate is a consultant with Daniel Penn Associates and instructor at College Unbound. She is the author of A Public Sector Journey to Lean: Fighting Muda in Times of Muri. [email protected] @KateMcGovern_

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The American Society for Public Administration is the largest and most prominent professional association for public administration. It is dedicated to advancing the art, science, teaching and practice of public and non-profit administration.

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