This week, I released an hour-long podcast with Nate Hurle, a Senior Director of Enterprise Continuous Improvement at Cleveland Clinic. In that full episode, we talked about the past year and what Cleveland Clinic has done in regards to:
- Ramping up Covid testing
- Ramping up Covid treatment
- Ramping up Covid vaccination
Here, in this blog post, we are sharing a transcript of the last 15 minutes, where Nate focuses on the vaccination process work. You can watch the video and/or read the transcript that follows.
At Value Capture, we have partnered with KaiNexus to help organizations share Covid vaccination process improvements (a free web-based system called "VacciNexus") and we now have participants from 30 U.S. states and 10 countries. We hope you'll check that out -- and request a free account if you want to learn and share. You can also read more about the origins and what it's intended to do in this post.
We'd also love to work with you on improving your vaccination process, so please contact us if you'd like to talk about that.
And we'll share some other related posts after the transcript.
Mark Graban: We've covered the testing phase, and planned ramp-ups, and starting to get back to care, and the different changes that have taken place.
Maybe the last thing we can touch on is vaccination. A new ramp-up, a different process. I was wondering, Nate, if you can share a little bit of the story there, and the process, and what you've learned, and what you, I'm sure, are continuing to learn.
Nate Hurle: We've had great team work on the vaccination process. I was personally involved in those first two examples. I'm not as involved in the vaccination personally, but our team has been. Holly Bourne from our team has been doing a tremendous job in that space, along with our pharmacists, and our nurses, and, again, our construction people, so on and so forth.
They followed a lot of what we created early on. You were describing that, Mark, in terms of let's develop what we think could work. Let's practice it. Let's mock it up. Let's make sure we have clear, robust process in order to be able to handle this.
I've been fortunate. I've been able to go through and get my vaccination. As I'm sure we do in any process we tend to enter, we watch it with a certain eye. "Hey, let's take a little closer look at this."
My observation in the vaccination process is, one, it is an efficient process in that you come in. You check in. You say who you are. Then, you go in. In our case, we have small little tents set up for privacy. It's inside a ballroom in a hotel that is attached to our campus.
After you have your vaccination, any questions? Nope.
I thought this was the best part. When we go around, we want to make sure that patients don't have an allergic reaction. Now, you have a lot of people to keep track of. How do you make sure that they actually stay for that 15 minutes and make sure they're OK? They just give them timers.
Timers. They press start. It counts down 15 minutes. Go have a seat in any of these seats. Timer goes off. You bring it back up. They clean it.
Mark: …is all digital timers. It's like the size of a business card kind of timer?
Nate: Yep, exactly. I thought that was a fantastic way because you have so many people coming through, how do you know, how does any individual keep track of 15 minutes? I thought that was an ingenious approach to put it in the hands of others, literally, with a timer. When this goes off, you're free to leave.
That has worked really well. We've been in the middle of vaccination within the State of Ohio. Again, I would say there's some similarities to what we were describing in the drive-through testing. You have the whole process of what the patient sees, in terms of the actual vaccination administration.
Then, you have the whole supply chain, the supplies beforehand. Keeping it really cold. Making sure that you take it out so you don't waste it.
Again, figuring out all of those details of, where are we going to put these special freezers? How are we going to get it from point A to the point of actual administration? How are we going to make sure that it has the appropriate time to thaw. Obviously, most importantly, how are going to make sure that we don't waste these precious resources?
Again, very common items to what we're used to when we think about process. We don't want waste. We don't want scrap that's thrown away, If we're making aluminum cans, we don't want to waste the aluminum. In this case, it's even more precious, in terms of what that vaccination represents for people.
We created processes to make sure that we didn't have waste. That was having a stand-by list. Very early on we created the stand-by list where we could call people. It says, "Hey, we had five no-shows today. Would you like to come down here next on the stand-by list?"
Mark: Going back to… Just two little details I'm curious about. When you're talking about the privacy, I've seen a lot of videos and pictures of different setups. Is privacy a matter of… I guess, if you're in a warm weather climate, people might have short-sleeved shirts.
Being Cleveland, if it's cold and people have sweaters and, I guess, getting access to arm may require a state of undress that people would want privacy for.
Nate: That was certainly a big driver in it, recognizing that when we started to administer it was still pretty cold outside. People were coming in with their coats, and their sweaters, and those types of things. That certainly enables it.
I think it's part of our patient experience element, as well. You were describing that earlier. How do you keep patients first?
I think it creates a tighter connection between the nurse or whomever is administering the vaccine and the patient themselves. It creates a space for dialogue or for questions, a little bit more calm in that particular moment. Obviously, as we know, there's a degree of nervousness for a lot of people. A lot of people are excited about it. A lot of people are nervous about it.
It gave them a space to be able to ask questions that was a little bit insulated from the rest of the public.
Mark: This thing of clothing. You might not have saw it, but Dolly Parton put out a video of her vaccination at Vanderbilt.
Nate: I heard about it but I have not seen it yet.
Mark: It's cute. It's very funny. She's sending an important message of encouraging people to get vaccinated. She wore a top. I forget what my wife called it. I was like, "Oh, that's a such-a-such top" ( the term is "cold shoulder top").
She had cutouts. It was a long-sleeved blouse, but just the style of the blouse had cutouts in the shoulder and enough down into her arm that gave a perfect window. That was an intentional choice, I'm sure, on her part. Perfect window for the vaccinator to come in with the needle.
Nate: Yeah. It's taking the setup steps and going from internal to external single-minute exchange of die principles. Dolly Parton was all over it, it sounds like.
Mark: I talked to somebody else yesterday when you were talking about that external setup. They had set up for each lane of people being vaccinated two teams. Basically, it was flipping in, flipping out. Doing the setup, and then coming in to work with the patient, and then team two is prepping. Having this constant cycling through to minimize the time.
In that video with Dolly, she actually gets a little… She was being cute about it, but she was getting a little impatient and fussy with the doctor because he's fiddling with opening the syringe package and the stuff that you and I would look at and say, "Oh, that should have been externalized. Don't make Dolly, don't make any patient wait. You can do that in advance."
It's really interesting to see how people are innovating and doing things to help improve flow.
Nate: We did that within the drive-thru. We chose not to do it within the vaccination, I think, because there's a design difference. Within the drive-thru space was very constrained. People changing PPE was even longer between patients.
We would have this team that would come in. They'd swab. They would come out. They'd work. Change their PPE. Wash their hands. Don their new PPE and come back. We essentially were able to do that to keep that flow of cars going because we were constrained in a physical space.
Where we are doing our vaccinations currently, we're not as constrained in a physical space. We've got to spread out the stations rather than them having swamping at the spot.
I think part of what you're getting there is you need to understand what problem you're trying to solve. Perhaps, if you're in one of these large megasites, as an example, maybe that is the way you want to do it. Maybe if you're in a smaller site you don't need to do that.
Understanding what problem you're trying to solve is really important before we go ahead and put in a particular practice.
Mark: That's a great reminder of taking a look at your own work and your own circumstances instead of just copying a best practice.
There are a lot of longstanding good practices at Cleveland Clinic. Here's a chance to recap. Again, I would encourage people, if you want some of the background, this is just a couple years ago, you can go back to Episode 282 and listen to Nate and Dr. Lisa Yerian talk a little bit more about the background of continuous improvement at Cleveland Clinic.
I think one thing that's noteworthy and worth looking at to learn from, not to copy, is the Cleveland Clinic Improvement Model. I was wondering if you could give the elevator pitch about that.
What is that model? Why has that been useful to be able to put in front of people?
Nate: Thanks for asking that question, Mark. This model serves as our aspiration. It is what we want to become across Cleveland Clinic in terms of the way that we improve. It's a unifying model. Quality improvements, patient experience improvements, productivity improvements, so on and so forth.
Really, what we do within the model is we outline the behaviors that we're looking for, behaviors of senior leaders, managers, and those that are doing the work each and every day because we all have different responsibilities. It's how those connect that drive our ability to improve.
Additionally, we've outlined, in our organization, what we feel is important, our four key system, organizational alignment, visual management, problem solving, and standardization. We feel those are important for us. For a different organization, it might be a different set of systems. It might be a different set of behaviors.
We use this as our aspiration and our roadmap and say, "This is what we want to create." Then, we create the systems to support the behaviors. You mentioned tiered huddles as an earlier example.
That is a system that we created to help our organization identify and solve problems each and every day. We do it throughout our organization every day where we are looking to understand what problems are getting in the way of providing care and solving and resolving those problems, as well as understanding our daily operations.
We create these systems that support the behaviors. Just before I came on with you, we were actually looking at the improvement model because every year we revise it. We improve it.
We realize that our organization continues to evolve and change. I was with a cross-functional team, people from other part of the organization outside of our continuous improvement team, getting their input on potential changes to the improvement model.
As you like to say, we improved the way we improve. That is something that we take really seriously. I was just starting to look through the past years and say, "Maybe there's a story here."
I go all the way back to the first one in 2014-15 and look at each year. What's the story of how it's changed and evolved over time? Part of that story is it has evolved as the Cleveland Clinic has evolved. Our focus on patients, empathy. Our focus on high reliability. Our focus on speaking up. All of those things are becoming stronger and stronger parts of our improvement.
Mark: There are certain principles that are very consistent. Patients First, I imagine, is forever a foundation at Cleveland Clinic. Then, some of the details and the specifics within the frameworks of values and principles then evolve and change.
Nate: Very true.
Mark: I hope everyone will go check that out. I'll make sure I'm liking to the latest revision.
Maybe one last question. Maybe we can leave this as a teaser for a future episode. Perhaps, when things calm down a little bit. You've had the opportunity to use process behavior charts, a topic near and dear to my heart. I won't go on and on about it, but it's a method that I've shared in my book, Measures of Success.
I was wondering, again, maybe just on an elevator pitch scale if you could share just a little bit. We can dive into that deeper some other time.
Nate: Yeah, I'd love to have that conversation because I think it's fundamental to these problems that we try to solve as a continuous improvement professionals, as we try to solve as an organization.
That is back to this question of first, what matters most? Which problems am I trying to improve? Secondarily, is this getting better, worse, or staying the same? That helps reinforce what problems I need to solve.
We've started to use them with the majority of our measures so that we can look at our performance over time and we can say things like, "This is essentially the same. It's not getting better. It's not getting worse. Maybe, for this particular measure, that's OK."
This measure staying the same might not be OK. We need to do something different. We need to engage in problem solving.
We use those. We've built a series of dashboards with our colleagues and business intelligence. They've done an absolutely fantastic job of making it very easy for the user to take advantage of this knowledge.
What I mean by that is you don't need to be a Six Sigma black belt to take advantage of what these tools can do for you. You don't need to have a degree in statistic or engineering to take advantage of these tools. We present it, in a way, for the user where the limits are automatically calculated. Whether or not it is stable or unstable is also automatically calculated.
In turn, what that allows people to do is say, "Ah, this is unstable," and to go understand why. That's how we're using it across our organization. We've made tremendous progress over the last couple years. We had you visit us a few years ago and share this, the thinking in your book with the team.
It has been absolutely fantastic and allowed us to talk about the things that are most important.
Mark: That's great. I like the way you're integrating that and incorporating that. I'll look forward to hearing more.
For those who are listening and not watching on YouTube, when Nate was saying "staying the same," you couldn't see his finger suggesting the fluctuation up and down, let's say, around an average. So "the same," it's not really the same but it kind of is. That's what…
Nate: Yeah, great point. I've got to work on my radio skills.
Mark: That's OK. For those of you who are just listening, you don't see that Nate is enjoying a bright sunny day in Cleveland, Ohio. Nate, thank you for not being outside in the sun and enjoying that. Thank you for being here on the podcast with us.
Thank you for sharing the important work that's being done and continues to be done at Cleveland Clinic. I really appreciate you being able to share that with us today.
Nate: Thanks, Mark. I'm here on behalf of an amazing team. I've been at the clinic now for 14 years. The reason is the people are absolutely incredible. The people on our continuous improvement team, our partners in the organization, in nursing, in quality, our providers. We have an absolute world-class team. We're blessed to be a part of it. Thanks for helping us share our story.
Mark: Of course. Thanks again.
Written by Mark Graban
Mark Graban has served healthcare clients since 2005. Mark is internationally recognized as a leading author and speaker on Lean healthcare. His upcoming book is "The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation."