By any measure, the United States is lagging far behind where it should be when it comes to distributing available COVID-19 vaccines and it is the people who are suffering. Just how bad is it going? Consider that Israel, a country of approximately nine million people, is vaccinating an average of 200,000 of its citizens each day while the U.S., with a population of over 300 million, is vaccinating just 225,000 citizens per day. Even recently announced plans to vaccinate 100 million people in 100 days still falls short of where we could be. States are scrambling to up their game and put in place the infrastructure now that should have been in place the day the vaccinations were available. while individuals and businesses continue to pay the price of COVID. In a life-or-death situation, we need to understand what is behind the vast differences in performance and how to close the gap. While the supply of vaccinations is an issue, government has fallen short of delivering what it can control—operations.

Israel has two factors working for them. First, they set an ambitious goal to vaccinate their entire population by early March. This, in turn, required they build out the operations needed to achieve the goal, and to do so prior to receipt of the vaccinations. Understanding what operational tools governments can use will not only help their response to the pandemic, but they are also applicable to almost every other aspect of government services and programs.

There are four operational principles governments should apply to improve their performance.

The Mindset—Policy vs Operations

You’ll note in the following Government Response Matrix that the vertical columns indicate when to take action. This is key, as government tends to respond after the fact.

The horizontal rows indicate the types of actions we can take. In government, we act as if policy is the only lever we can pull—we enact more policies, more restrictions, and more public awareness campaigns—while ignoring the role operations can play in the solution. Operations are key because it is the area over which government has direct control while policy is focused on changing and influencing the behaviors of others.

For example, in the response to COVID-19, governments have focused on imposing policies and restrictions on the public that required that they change in life-altering ways, including risking their livelihoods, isolating from loved ones, and adopting significant behavior changes. While these measures help limit the spread of the virus, it is equally important that the institutions asking the public to change commit to change themselves—and by the same order of magnitude.

The following four principles highlight key operational changes government should adopt.

The Government Response Matrix

Principle One
Think Like a Firefighter, Build in Buffer Capacity

Firefighters have a lot to teach us about how to plan for unforeseen spikes in our work. For instance, firefighters do not actually fight fires every minute of every shift—in other words, they do not “keep busy.” Rather, we pay them to be available and ready to go as soon as a fire starts.

We should have roles just like that.

Why? Because as hard as we try, we can’t predict the next spike in cases, or how many new applications we’ll receive this month. Uncertainty is a fact of life we cannot escape. Therefore, it is essential that we build and maintain an appropriate amount of “buffer” in our operations.

Buffers act as shock absorbers for the entire system, so that spikes in work can be absorbed without affecting performance standards. It allows us to choose deliberately where we want to invest—upstream in mitigation efforts, or downstream as we reap the consequences of under-preparation.

While this is common sense, we seldom operate like this, as we feel it is wasteful not to have every resource working at full capacity all the time.

Consider how this operational concept applies to COVID. Although governments and public health officials across the country eventually embraced strategies of proactive testing and contact tracing, some failed to implement sufficient buffer capacity.

The following vicious cycle thus emerged:

Cases spike and overwhelm the system
Workers cannot stay on top of their work and backlogs grow
Everything takes longer
Turnaround time on testing and contact tracing grows, which contributes to more spread
In some cases, public health officials begin prioritizing contact tracing and abandon it for defined groups who tests positive
This leads to secondary spread and more cases, which contributes to system overwhelm

A system without sufficient buffers is a catastrophe waiting to happen, or, more than likely, is underway. A healthy system is one that anticipates fluctuations and invests in enough “firefighter-type resources” up front so it can absorb new workloads without compromising speed or quality.

This concept is critical when it comes to vaccinations. It would be devastating for vaccinations to be available and for citizens to be prepared, only for the healthcare system to fail to distribute the vaccine because it didn’t invest in enough personnel to administer the shots.

It would be much better to over-invest in qualified personnel and sites now, vs. paying the societal price for the vaccination process to take much longer than it should.

The need for planned buffer capacity is everywhere in government. Consider:

The cost of people waiting in jail because of insufficient capacity in the courts
Child welfare investigators who need the seasoned input of their supervisor but can never meet with them, because the supervisor is spread so thinly. This extends the time to complete a quality investigation—creating negative consequences for families and children.
Failing to set aside sufficient rainy-day funds to provide a safety net during economic downturns.

Buffers aren’t needed everywhere, and there are several variables to consider when calculating need, but even before making these assessments we must first overcome the desire to be “efficient” everywhere. Buffers are about choosing where to pay the price—upfront, where downstream effects can be mitigated, or downstream, where the consequences are much higher. In many cases, new resources aren’t necessary. Instead, it requires rethinking how existing resources are being used and how to create more capacity with what we already have.

Principle Two
Get to the Fire Quickly, Speed is a Big Part of the Solution

Having firefighters available is critical, but even this isn’t enough. The time it takes for firefighters to arrive on scene determines whether the fire is extinguished or burns the structure to the ground.

Therefore, what we do to combat the virus is important, but it is often speed that determines whether or not we succeed.

For example, like the firefighters, robust testing and contact tracing are only as effective as the speed at which these tasks are performed. Due to a short incubation period before an individual becomes infectious, the more quickly an individual is tested and their contacts traced, the more likely we are to limit the spread of the virus.

For example, let’s say Susan becomes infected. She only learns of her positive result five days later, and it takes another two days for public health to contact her to determine who else she may have infected. Within the first five days, she could have unknowingly transmitted the virus. But even more concerning is the people who may have contracted the virus from Susan have no idea they could be carrying the virus until the seventh day, when Susan shares her contacts. By then, Susan’s contacts could have easily transmitted the virus to multiple people. This is how exponential spread occurs.

The need for speed extends to vaccinations. The time elapsed between health care facilities receiving the vaccine and administering it is a key lead measure. While buffer capacity is part of the solution, using operational techniques to shorten the time between these two variables will affect how quickly citizens get vaccinated.

Speed also requires minimizing friction. Friction creates resistance and slows down a system. It is key to consider what “friction” points citizens may encounter when getting vaccinated. Israel has hundreds of clinics dispersed across the country so vaccination sites are convenient and accessible (for reference, Israel is smaller than Utah). Bringing the vaccinations to the people—especially populations who may have a hard time traveling to sites, is essential.

Friction is showing up in other areas and wasting time and capacity. Scheduling vaccination appointments is currently a challenge, as is collecting the names of people who want to get vaccinated so they are quickly alerted and scheduled when more vaccinations are available.

Despite the fact that speed is key to combating the virus, it is woefully neglected and under-reported. It can also be overlooked in many other government functions. How quickly a key piece of equipment is repaired so it can get back to doing its job matters. How quickly a permit is issued matters. The speed at which a road project is completed matters. How long a citizen waits for a critical service matters. The list of examples is endless.

Often, we believe that in order to increase speed, we need more resources. While that is sometimes true, operational techniques can accelerate work using existing resources. For example, ensuring that all requisite information, tools, resources, or decisions are made before work moves to the next phase reduces rework. Triaging work so that simpler work is touched once and completed frees up capacity to work on more complex work. Knowing how to create the ideal “batch” size helps ensure work never gets stuck. Creating simple operational measures that flag a person or task that isn’t moving can accelerate appropriate intervention.

Principle Three
Bring Enough Water to Put Out the Fire, The Significant Role of Dosage

Of course, if the fire chief adopted the previous recommendations (implement buffer capacity and improve speed), the work still wouldn’t be done.

Firefighters also need access to sufficient water and chemicals to put out a fire. In operational terms, this means having enough “dosage.”

The concept of dosage is common when we think about medication. If we want the medication to work, we have to take enough of it to make a difference. Having the right medication, but at an insufficient dosage, won’t address the health condition in question.

Dosage is also a powerful operational tool, but it isn’t well known or used. Let’s consider its application to COVID.

As mentioned above, government and public health agencies have increasingly—though slowly—adopted asymptomatic screening and testing as part of their core strategy. As case numbers increase, those who are infected but remain asymptomatic and untested also increases. These individuals pose a serious risk to further spread.

How can the public health system detect these individuals? Dosage is the key.

Consider a state where 2,000 cases are identified per day in traditional testing of symptomatic individuals. The local public health agency wants to adopt asymptomatic screening and testing to help slow the spread. It sets a target of finding another 2,000 positives per day. This means their daily tests would need to increase by approximately 100,000. [Note: A two percent positivity rate means for every hundred tests administered, two people test positive. Therefore, if we want to identify 2,000 new positive cases per day, we need to administer 100,000 more tests (100K x 0.2%)]

When we understand the testing, dosage needed to find asymptomatic individuals, we can better plan for the deployment of key resources. If testing capacity is limited, it is far better to focus it rather than spreading it too thinly.

For example, if this same public health agency has limits on the amount of testing it can perform, they should focus their resources in areas where they can slow the spread the most. If an area has a positivity rate of 10% (vs. the 2% that may be common in other areas), it will only need an additional 20,000 tests vs. the 100,000 in the first example. In both scenarios, dosage helps decision makers take proactive steps to understand how much testing is needed to limit the spread.

Too often, we assume we can only use what we have rather than determining what we want and need according to an ambitious target and a clear operational strategy. Dosage requires that we determine how much we want over what period of time.

The implications of high dosage when it comes to vaccinations is clear. The more people who can get vaccinated over a defined period of time, the quicker we can save lives and return to a more “normal” way of life. The current focus on managing which populations get vaccinated first is a result of insufficient dosage. For example, if a state had enough vaccinations and sufficient infrastructure to vaccinate all of its citizens in one month, managing priority groups would become less relevant as herd immunity would occur quickly. While this scenario assumes ample access to vaccinations, the principle is still true. Setting aggressive targets using available vaccinations forces the discussion of how much infrastructure is needed to achieve the target within a defined period of time.

Implication of Dosage across all areas of government

Imagine the implications dosage has in other areas of government. Think about an inmate leaving a county jail or prison. Traditional approaches “sprinkle” support and intervention across three years. Dosage considers how much support an individual may need within the first 90 days to achieve momentum and early success.

Or consider the leadership of a government agency making major decisions. The traditional approach would require meeting on an issue for an hour, once every two weeks or so, for months. A dosage mindset would encourage decision makers to pick a decision to make, sit in a room for a day, hash out all of the questions they need to discuss, then make the decision and move on.

Dosage clarifies the relationship between time and the quantity of something needed to achieve the desired outcome. This allows decision makers to plan proactively and drive results rather than haphazardly using what they have. Dosage also helps achieve early wins and build momentum in the right direction.

Principle Four
We Need Signals to Tell Us When to Act, Not Just Reports that Tell Us How We Did

Imagine a traffic system that didn’t use any light signals or signs to help people know what to do, but instead relied on lag measures and messaging to manage traffic. In other words, those who ran the system would report out, after the fact, how many crashes occurred and how many people were injured. To try to reduce accidents, those in charge would use public awareness campaigns and more training to encourage people to drive carefully. When accidents increased, the traffic authority would limit the number of people who could use the roads until the accidents decreased. Once accidents fell within acceptable levels, those in charge would allow more people to drive on the roads until accidents hit unacceptable thresholds. Then, the cycle would repeat.

This sounds like a ridiculous scenario, but this is often how we run our organizations. We rely on lag measures that tell us what happened after the fact and fail to manage to lead measures that provide our organizations with the “signals” they need to take the right actions before it is too late. Importantly, while we cannot control lag measures, we can control lead measures. In the above scenario, the transportation authority can ensure all roads have appropriate signage, traffic lights, and well-engineered roads. If done well, these signals will positively affect the end goal of reducing crashes and fatalities.

Consider the implications of using lag measures when it comes to managing COVID.

Many states have now experienced multiple oscillations in their respective COVID cases. Case volumes increase, then decrease, then may cycle back to a larger increase, and so on.

Government attempts to react to the spread primarily through policies and guidelines that increase or decrease restrictions (such as wearing masks, limiting business activities, and social distancing). As numbers appear to decrease, restrictions are lifted. Things appear to improve. Human contact increases. The spread of the virus accelerates. We hear that cases are on the rise. More severe restrictions are put in place, and case numbers go down. We’re always chasing our tail.

This oscillation dynamic and our collective reliance on changing restrictions clearly indicates that we are acting from lag measures (such as positivity rates. By the time these lag measures signal we need to make a change (meaning modify restriction levels), the damage is done—the spread has already reached concerning levels. As cases rise, the workload can quickly consume the system’s capacity and spread already limited resources too thinly. This exacerbates the spread and compromises the ability to contain the transmission.

Focusing on lag measures is a tempting trap, as they ultimately define success. However, if the focus shifts to the proper lead measures that influence the lag measure, then working teams and project stakeholders will have the signals needed to remain on track and, more importantly, course-correct when they deviate.

With COVID, lead measures could include time from testing to contact tracing and monitoring unacceptable thresholds to know where to divert buffer capacity. With vaccinations, lead measures could include time of receipt to time of deployment, again monitoring thresholds to know where to divert buffer capacity.

Questions to ask when creating lead measures:

What do you have direct control over?
Where is the real value in the organization created for the customer and how can it be protected?
What does the flow of work look like and how can the agency measure and monitor performance against standards?
Is the agency providing the right service, in the right amount, and at the right time according to what the customer needs, not on the status quo?

These questions point to four of the key rules of operations that can make or break how well an organization performs. Government must stand back and ask the hard questions: are we doing our part and what else can we do to better serve our citizens?

Conclusion

We can create innovative, powerful solutions when we apply this sequence of simple-yet-profound principles:

Look for the areas in our operation where we need to have a “firefighter” mindset to build buffer capacity proactively
Work on how quickly we can “get to the fire” and respond to the needs of our customers
When we arrive, make sure we’re prepared with enough dosage to “put out the fire” and produce the results our customers are counting on
Ensure we’re looking forward to the road ahead, not fixated on the rearview mirror—especially when we have our foot on the gas. In other words, build clear signals into systems that tell us when to take action, not just rely on lag measures

We’ll certainly look back on 2020 and our collective COVID response for years, but we can apply these lessons directly to our immediate vaccination efforts, and to whatever other challenges await us in the future. It will require us to start with a mindset of extreme responsibility and to expect much more out of ourselves and our organizations. Leaps in performance occur when we learn new skills and principles; not by doing more of the same. The public needs and deserves a stronger operational vaccination strategy.