Continuous Improvement Methods Help Fine-Tune Drive-Through COVID-19 Testing

Through collaboration and continuous improvement methods, Cleveland Clinic met the challenge of rapidly creating drive-through COVID-19 testing

Drive-through testing

On the morning of Tuesday, March 10, 2020, executives from Nursing, Continuous Improvement, and Operations stood in the emergency command center on the Cleveland Clinic main campus to prepare and assimilate the impact of the rapid escalation of COVID-19. Concerns were mounting as the spread of the mysterious contagion had already affected a growing number of countries.

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As the team assembled to escalate Cleveland Clinic’s response to this virus, grave concern showed on their faces. One of the many preparations that were underway was determining how symptomatic patients would be tested. A challenge was given to create drive-through testing and to begin testing within three days. The global pandemic would be declared on March 12. 

Caregiver and patient safety was the top priority. It was clear that keeping everyone a safe distance from the contagious disease was paramount, and it was understood that compromised and potentially infected patients walking into clinics for testing would be problematic. There was some knowledge of drive-through testing in other parts of the country. However, it wasn’t exactly clear what drive-through testing entailed, nor where it could be held, how it would be done and who would manage it.

Drive-through testing: Putting patients first while protecting caregivers and their families

Without trepidation, the ideation began and the team from Continuous Improvement was poised to bring their specialized insights to the table, and the whiteboards, so to speak.  

Nate Hurle, Senior Director, Enterprise Continuous Improvement, quickly brought clarity to the situation using continuous improvement methods at the onset. The team was encouraged to identify the basics. Conversations were captured with a number of leaders. Associate CNO Shannon Pengel, RN, MSN and a nursing team of Assistant Nursing Director Laura Idzior, MBA, BSN, and Nurse Manager Zoe Zelazny, MA, MSN were identified to run the operation. Finance was tapped for the registration of patients as well as Facilities and Operations because of the need to physically build the site.

Pengel described the start of their work as an endless list of questions about procedures and personal protective equipment (PPE), “Where will we do this? Who is going to do this? What is the best procedure for doing this? We’ll be outside. PPE is needed. How long can you wear PPE? There were so many questions as we started brainstorming different ideas. How are we going to train people—and so quickly?”

Breaking It Down To Build It Up

Hurle identified three key guiding principles:

  1. Focus on what is the most important problem to solve
  2. Don’t worry about making it perfect; focus on making it better
  3. Give rapid feedback to quickly gauge how things are going

The nursing team began by gathering supplies to simulate administering the test itself. Team members gathered the necessary materials to outfit the experience in a conference room with chairs simulating cars. The team set to work to resolve the primary problem—how to administer the test to patients safely and effectively inside vehicles. Hurle described how they collaborated across functions and teams, “Infection Prevention was there as well as many from the Nursing team. We walked everyone through this process in great detail to figure out each step. What was the work that we were going to do with patients when they arrived? What did we need to tell them? What is the sequence? And so forth. We just iterated on this over and over again.

“We started with the basics knowing the only perfect part we needed at the beginning was people’s safety. Then we explored how we could begin to scale it to make it better.”

Pengel described the scene as they worked together using the CI processes, “It was beyond chaotic. There were so many moving parts and so many teams that had to be involved. The beauty of CI is they put everything in black and white. They created lists. ‘This is what we’re going to do, steps one through 10.’ We needed a process that was easy to follow.

“They were wonderful at identifying the problems and then helping us rework everything. For example, we started that first morning with what we thought was a really good plan. And then new concerns came in that needed to be factored into the equation. Nate and their team would turn it into a solution. CI leaders are skilled at prioritizing all of these processes.”

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Simultaneously the physical site was being set up with power, WIFI, signage and importantly, heat as we were set to begin this process in a parking garage with 30-degree temperatures in March in Cleveland. The site opened on Saturday at 11 a.m. to see the first patients—just four days after the work had begun.

Hurle describes a key metric for measuring the process of improvement, “In that first hour we were able to see about 30 patients. Three days later we were able to see 115 patients an hour. There was real magic in that change.” The team could see and feel the progress, and they were eager to see immediate improvement.

Making it better through rapid feedback and measurement

Hurle’s expertise in continuous improvement brought simple tools and action steps to an eager team to enable them to create and improve the work. He describes the hectic pace of the first few days of the testing center in action, “We set up large whiteboards that sat on wheels, so that we could easily move them around and constantly track changes. We said to the team, ‘Hey, we’re going to change how we do our work. How we start the work Saturday is not how we’re going to do our work on Sunday—because we’re constantly making it better. I don’t know what the change is going to be. We need something that is easy to change because we’re going to learn very rapidly and make adjustments.’ This allowed us to be very flexible in terms of how the site was set up, as well.” Using the CI principles allowed leaders to give feedback in real-time, not one month later. The team was rapidly solving problems, one at a time.

Hurle described how he coached the team through the steps, “Okay, what’s the most important problem we need to solve in the next thirty minutes? Because there was a big long list of problems. And when I say problems, it was really opportunities to increase throughput and to make sure that we’re doing everything safely.

“And so together we would decide what that next problem is and then we’d go and we’d work on that problem for the next thirty minutes. It was this constant series for the next three days of defining what the most important problem to solve is now, and go and work on it.  And it was super-fast.  We’d say, ‘Okay, this is better than what it was. Great. Now, what’s the next problem to solve?’ We didn’t focus on being perfect, we focused on making it better than what it was.”

The PDCA Cycle: Plan, Do, Check, Adjust

Another continuous improvement principle that served the team well was the Plan, Do, Check, Adjust (PDCA) Cycle. It is a well-known continuous quality improvement model of a logical sequence of four repetitive steps for continuous improvement and learning.

  • Develop a plan
  • Implement, or do the plan
  • Check to see how it is working, and
  • Make adjustments based upon what you see when it’s working

In this case, the team developed a plan that was implemented when the testing site opened on Saturday, and then within an hour-and-a-half to two hours of checking results, it was adjusted.

Through measurement, they were able to track how long it took for cars to approach while completing the calls. While tracking the line of approaching cars, they observed and recorded problems that were encountered. Towards the end of Saturday, a bottleneck was clearly visible as a result of the direction the cars were headed in the garage. There was a delay between registration and swabbing, so a plan ensued to have two registration bases. The adjustment to registration was made overnight allowing four cars abreast to improve throughput. The PDCA cycle was followed in various ways for the entirety of the first three days.

Visual management conveyed messages quickly and invited interest 

Visual Management is a key practice to use for providing feedback to a team on performance of a process. Early on the team recognized that tracking the quantity of patients treated per hour on a whiteboard was an effective way of giving feedback in real-time. We soon learned that the growing number of cars stretched along the major roads in the city—cars with anxious patients trying to get into the testing center—became the biggest problem. The feedback was very simple: how many patients were treated every hour.  

Hurle described excitement about seeing the solutions to the problems, “Emotionally it was difficult because there were all these people driving through our site each day who were absolutely scared. Cars were in line five or six hours. One patient arrived seven hours before we opened and slept in his car. The City of Cleveland Police came to check on us because the city streets were backing up. And we were dealing with frigid weather. It got worse on the second day and although we saw concern in their faces we had to close to any new cars at three PM. These things really weighed on us. We knew our challenge was to increase capacity. Increase capacity. Quickly.”

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Simple feedback provided inspiration. For example, as the lab team came to pick up the testing samples every 90 minutes, a simple count of the quantity was written on the whiteboard. An increase in the count became the basis for becoming more efficient with each passing hour.

“That became such a motivator for the team. Now you can imagine car after car after car, the line’s not going away. So you can’t get motivated and say, ‘Look guys, we’re all caught up.’  Because we were never going to get caught up. It was amazing watching these individuals, the whole team, swabbing patient after patient. And then they’d see the lab person and ask, ‘How’d we do? How’d we do?’ as they recorded the counts on the board. They were incredibly enthused by that. And it also enabled conversations around, ‘How can we make this better? How can we make it easier for you? How can we take better care of the patients? How can we get more patients through?’”

A valuable study in continuous improvement

Hurle summarizes how straightforward CI concepts transformed a COVID-19 testing center into nearly magical experiences, “It always starts with ‘What’s the problem we’re trying to solve?’ That’s a clarity discussion. Often we do not have clarity. We need to ask questions. Not ‘What’s the solution,’ but ‘What’s the problem?’”

Establishing a Continuous Improvement initiative comes with a word of caution: do not over-analyze. Hurle recognizes that leaders may make the analysis too complicated or make the implementation too difficult. He reports that they often want to implement across the enterprise all at once. In this case, a smaller initiative allowed for rapid change and improvement.

“We were able to document results each day recording the total number of patients tested each day: Saturday, 300 patients. Sunday, 550. Monday, nearly 700. We were able to test 30 patients an hour on the first day eventually increasing up to 115 an hour without increasing the number of workers,” said Hurle. “This was a physical process that we could watch. Clearly, this improvement wasn’t through more people; we did it by improving the work. You don’t have to solve all the problems by hiring.”

Pengel gives praise for exceptional measures and practices ensuring the safety of all the caregivers. She also gives recognition to the team who is maintaining the testing and the operations as the pandemic continues, “I am proud of our team of teams and want to recognize the ambulatory surgery staff that has volunteered to maintain its operation serving all residents in need in the greater community – not just Cleveland Clinic patients. 40 or 50 have volunteered for the long haul. And our lab caregivers have performed more than 395,000 tests for COVID-19 since the inception of the testing center.” 

Addendum: Feedback upon feedback

Team members were enthused and enriched as a result of this initiative and shared a few highlights with their managers:

  • The Cleveland Clinic Police were so valuable and helpful to us from day one!
  • Appreciating the Walker Wellness staff for their support, healthy snacks, socks, and coloring sheets.
  • We had people from across the enterprise deployed to Walker building (testing site).
  • Everyone came from different backgrounds with many different titles and we ran like a well-oiled machine and great team!!
  • When a car broke down, we made a makeshift lane to keep the line/process going while pushing them off to the side
  • Singing happy birthday to a patient we swabbed that had lost her husband to COVID 19 the week before.
  • Everyone would clap and cheer for the pediatric patients.
  • On someone’s last day at the site, they would clap out their friend.
  • Cheering the first few days when they reached the end of the endless line of cars.
  • One patient blessed team members with Holy Water after they swabbed her.
  • So many memories packed into the longest yet shortest time with the best team ever!
  • Support from the community! So many donations:
  • Homemade masks
  • Homemade mask holders to protect our ears
  • Box lunches, coffee and tea every day
  • Donated lunches and lotions
  • Girl Scouts Cookies