Creating an Operational Masterpiece: How a COVID-19 Mass Vaccination Clinic Took Shape

In the following excerpt from Episode 19 of The Idealcast, Gene Kim and Steven Spear interviewed Trent Green, SVP and COO of Legacy Health, on how he and his team used iterative problem solving to vaccinate 8,000 people a day at Oregon’s largest mass vaccination clinic.

Key learnings from this excerpt include the idea that organizations are really a collection of interdependent microsystems, that you can’t improve a process until you stabilize a process, and sometimes you have to slow down to speed up.

Gene Kim:

Trent, I’d love to rewind the clock to January or whenever that was when you realized that you might be responsible for standing up a big part of the mass vaccination clinic. Can you talk about what those first days of operations were like. If I remember correctly, you said you were struggling to get 2,000 doses out a day and eventually heading to 8,000. So, can you describe what that felt like in the early days?

Trent Green:

It was a long story that we don’t need to rehash on how we got to ultimately standing up a mass vacs site. But when we concluded that we needed to do that, you’re right, we ran an operation scheduled to operate 10 hours a day, very frequently operated 12 to 13 hours a day. We were lucky if we could crank out 200 doses an hour and ultimately get 2,000 doses in people’s arms during a day. 

It was extraordinarily high stress. We were trying to be as efficient as possible, but we had never done something like this. What we actually put together was a collaboration of four competing health systems. So, you had that dynamic to manage, but also just the complexity of doing it. We immunize patients every day. We don’t immunize patients with a two-dose regimen that has a lot of care and handling on the actual pharmaceutical side. So, that added the complexity.

What we found is, back to these systems and improving systems, we had all these microsystems. We had a registration microsystem. We had a vaccination microsystem. We had a pharmacy microsystem. We had an observation area microsystem. 

What we didn’t understand in the beginning at all was how, as you made a change in one of those areas, we forgot that we needed to evaluate the implications in the other microsystems. So, we created a lot of our own problems and it took us a while to get to where we are now. 

We’re administering close to 8,000 doses a day. We do that in seven hours. So, over 1,100 an hour is what we’re up to. Now, we can do it in less than 30 minutes and that includes the 15 minutes of observation that’s required.

We could never do that in the early stages. So, we’ve made a ton of improvement.

 I think one principle that I learned early was, you can’t improve a process until you stabilize a process. One of the things that we struggled with early on is, people would have bright ideas, “Oh, we should do this. We should do that. We should do this.” We attempted to stack way too many improvements on, and it would just make things, frankly, it made things worse either in that microsystem or in another microsystem. 

So, we learned, and then we started to slow-walk our improvements a little bit and do a better job of testing things before we [would] actually, ultimately, implement.

Gene Kim:

Before we talk about the mechanics of that, could you talk about maybe some of the major milestones as you went from 2,000 a day to 8,000 a day? What strikes as the breakthroughs that you would point to in that journey?

Trent Green:

Yeah. So our first date of operation at the Oregon Convention Center, which is where we run this mass vaccination site, was January 25th. First administrations would go in people’s arms at nine o’clock in the morning. We would have people there at six in the morning doing training, doing walkthroughs, making sure everybody was in the right chairs. 

Theoretically, the last appointment was at seven o’clock at night. But as I mentioned, we routinely went over in those early days. There’ve been so many improvements. I’m not even sure where to start. 

I think some key milestones for us have been, we’ve never wasted a dose, never wasted a single dose. Now, oftentimes, what that meant is [that] at the end of the day, if we overproduced in pharmacy—again, one of the microsystems—if we overproduced in pharmacy, there’d be a lot of people on the phone trying to find people that were eligible to receive the vaccine that could come to the convention center quickly.

We now have a process down where we are extremely efficient at the end-of-day operation, so oftentimes we’ll have to open up another vile to finish the day. But we still don’t waste and we don’t have to find 50 people at the end of the day to administer the vaccine to. 

I think key milestones were a stabilization of processes. We’ve actually reduced hours now. So, as I said, we were doing 2,000 in 10 hours, which often ended up being 12 hours. We’ve now moved it to a 7-hour operation. 

What we found is, the burnout was real. It’s intense when you’re in there, and recruitment of volunteers or paid staff and so on and trying to run multiple shifts just became too complex for us. So, we actually got faster when we condensed that time. So, we went from 10 hours… For a period of time we ran 7:00 AM to 7:00 PM.

That was really taxing for people. So, now, we’ve moved the operation to five days a week, 7 hours a day. 

And for instance, my daughter’s 16 years old. She became eligible two weeks ago. Last night, I took her to the Oregon Convention Center. I was such a proud father walking her through. She didn’t really care about all the things that Dad had done, but we were in and out in 34 minutes. 

Now, that included 10 minutes of waiting because we were one of the last appointments of the day. And at the end of the day, we do do what we refer to as a pharmacy draw down, where we slow down the process a little bit so we don’t overproduce.

Gene Kim:

Awesome. [When I visited] it was such a heady day. And one of the things that really caught my attention was how you moved the area of operations from one of the banquet halls to the huge 116,000 square foot area. Can you talk about what led to that?

Trent Green:

Yeah, so we started out actually in, as Gene mentions, in a ballroom. We thought that would be sufficient space for us. But this [was] even another learning. We didn’t design that space very well. 

We had, I would call it a waterfall concept. So, you would enter the ballroom, that would be where registration was. Just behind registration is where the vaccination center was. And then the waterfall concept was, you either went left or right and that’s where the observation would occur. 

Well, the problem with having two observation centers is, we had to double the number of staff. We had to have double the number of people sitting in there. We had to have two medical tents for people. So, we built in some inefficiencies in the beginning. 

We also realized we just didn’t have enough space to process. We could only end up doing about 500 per hour max in that space. It just wasn’t enough. So, we moved to the exhibit halls where we had ample space. And then we modified our approach where we created six pods. The pod strategy was really key because it just enabled people to move that much more rapidly and us to process that many more people efficiently.

When we first moved to the space, we actually had a consult from Starbucks. So, Starbucks had been very involved in the state of Washington and their mass vaccination operations. And so, I met this gentlemen, Josh, at the convention center in February, the first day we had moved into the new space. He said, “Well, do you mind if I take some time studies. I’d be happy to give you some suggestions for improvement?” I said, “No, that’d be great.” He spent, I don’t know, half a day there, observed all of our systems, came back, sat down with me, and said, “I got to be honest, I don’t really have any suggestions for you. You guys are doing such a good job of processing. I want to go back and study this a little bit more.” He said, “You might be able to open one more pod, but beyond that, keep doing what you’re doing.”

Gene Kim:

That’s great. In fact, I’ll put a link to the FEMA video that was put together that featured the Starbucks person and the back of your head too, Trent. Before we get to Steve, when you look back at this, what are you most proud of getting to the vaccination clinic this far?

Trent Green:

Well, to be a healthcare…any role in healthcare in the last 14 months, it’s been hard. February 28th, 2020, is when our first case was identified in the state of Oregon. 

I still remember that day. It was a Friday night. I was supposed to be at a high school girl’s basketball game, and I spent the entire time out in the parking lot on the telephone trying to figure out what to do. 

The last year has been hard emotionally. It’s been hard for people management, for protective equipment. I have to say, though, this vaccination effort has been a bright spot for me personally. I get so much joy. One of the things we lose, I think we’ve lost, is the recognition of how important smiles are with masks. It’s really hard to tell when somebody’s smiling. But I can tell you, when you go to the Oregon Convention Center and you walk around, you see everybody in masks, you can tell they’re smiling. You can see it in their eyes.

And that’s just been really gratifying for me. We worked with the governor to actually move teachers ahead of seniors. That was a controversial move, but Oregon had been very slow in restarting schools. And we worked with superintendents of schools who were phenomenal partners to help us test our systems. Again, we didn’t know how to do this and they were organized. We were organized. We figured out a way to get them scheduled efficiently. 

Gene, I’m going to remember this for the rest of my life, the role that I played in this vaccination effort. And it’s just been really personally gratifying for me and for our people. I can tell, people’s spirits at work have even been lifted. I’m now vaccinated and they’re vaccinated. And there’s still protection, but it’s been really hard in healthcare and this has been a bright spot in the last 14 months.

Gene Kim:

I just read that amazing article in the Willamette Week describing the vaccination site as a magical Disneyland, like the best airport in the world, like an f-ing Swiss watch. That’s got to feel pretty good.

Trent Green:

Yeah. It’s very gratifying.

Gene Kim:

Steve [Spear], you had told me something some months ago that, literally my jaw dropped and that also became the focus of lots of effort and other studies. You made the observation that some hospitals, as they’re delivering vaccines, can get a 100% of vaccines in people arms. But some are struggling to get 30%. And then you also made the observation that some school systems, once the decision is made to return to in-person learning, some can reopen on a dime, maybe weeks, others take months or quarters. 

You made the claim that both of those are probably a very good proxy for an organization’s ability to adapt, learn, act upon learnings, re-engineer all the relevant processes, and really unleash the creativity of the entire workforce, especially on the front. To what extent does the story that Trent told affirm your hypothesis on a scale of one to 10? One is not at all, 10 is exactly in line with what you expected.

Dr. Steven Spear:

Yeah. I’m going with a Spinal Tap. This is an 11.

I just want to, first of all, say thank you to Trent and his colleagues for all the hard work they’ve done both in the gloomy times and now to get us to the end of the tunnel. 

Just to put things in perspective, people were talking about having to be a masked society well into 2022 and even 2023. And the fact that by mid 2021 we’ll have some return to normal is fantastic. And again, to Trent and his colleagues, who during the dark periods, they took on real personal risk to help usher the rest of us through this terrible event. What I’d like to encourage anyone listening to this is to listen to Trent’s account with great appreciation. It’s well-deserved. But also to recognize that in his account, there’s some general lessons which are applicable to them too.

I’ll just pick up on a couple. One was this idea of, the problem was we didn’t run a system, we were running a series of microsystems. 

That is common, and Gene and I have spent a lot of time talking about why we end up with these very complex organizations, which looked like these kind of loose confederations, loose collections of microsystems that don’t really come together. 

The reality is, that’s true, and where you get systems of systems—to parlay one of our favorite books, Team of Teams—is by actually having someone draw the line through the systems to figure out the sequence, the dependencies, by which value gets created. 

When you start seeing the system of systems, then you can start doing all the system level improvement to make things better. 

So, that was one point. And again, why I encourage people to listen, beyond the well-deserved appreciation, is that anyone listening to this podcast, they are probably working within a microsystem, which is part, not part of a microsystem and a larger system, it is a microsystem next to a lot of other microsystems.

The second thing that Trent said, of the many things he said, but the second thing that comes to mind is this idea that first we need a standard before we start to improve. And that’s so key, because until we actually make a sound declaration of what we think is going to work, we can’t find out if we’re wrong. Until we create a standard, create a declaration, set up the hypothesis for an experiment, it’s just air confetti, it’s just nothing.

Even if the first standard you create is going to be deficient in some way, at least you can see the deficiencies in the standard and then quickly close the loop and find out what’s wrong with the standard and modify, modify, modify so that you get to a better standard, whether it’s the realization that waiting to the left and to the right complicates things. Fine, one waiting place. From one location to another location, fine. Again, that wasn’t in the first standard, but it was in version 3 and 4 and 12 and 24 and et cetera, et cetera. 

[So] we live inside microsystems rather than a system of systems and you need a standard to make an improvement. But the [third] is, where Trent ended, you can see the smiles behind the masks. February 28th, 2020, no one was smiling. But when this kicked off, with your mass vaccination, probably, January 2021, still, no one was smiling, even though you were giving vaccinations, because it was just so overburdensome. It was so frustrating, it was so difficult to actually do the right thing.

And now here we are in mid April, and people are doing “the same work” but they’re doing it with gracefulness. They’re doing it with appreciation.

And the thing I just want to offer, why is anyone ever asked to do work where they can’t smile with the sense that they’ve done something that someone else will appreciate? 

I almost have to get to the point that, it’s a choice that we make and that people responsible or other people make. We make a choice as to whether we’re going to be energetic and open-minded and inquisitive, like Trent and his colleagues, and try to get systems to evolve and adapt and adjust so that the people in this system want to smile because they know that they’re doing something appreciated. It’s an alternative that’s chosen, if we don’t do that. 

To listen to the full interview, head over the The Idealcast page or listen on your favorite podcast service.

- About The Authors

Gene Kim

Gene Kim is a Wall Street Journal bestselling author, researcher, and multiple award-winning CTO. He has been studying high-performing technology organizations since 1999 and was the founder and CTO of Tripwire for 13 years. He is the author of six books, The Unicorn Project (2019), and co-author of the Shingo Publication Award winning Accelerate (2018), The DevOps Handbook (2016), and The Phoenix Project (2013). Since 2014, he has been the founder and organizer of DevOps Enterprise Summit, studying the technology transformations of large, complex organizations.

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