Best Practices for Implementation of an Employee Health COVID-19 Vaccine Clinic—A Model for Future Pandemic Preparedness

Population level workplace interventions can be used to create safe, equitable vaccination programs. The success of future, large scale vaccine clinics can be enhanced by utilizing best practices, which can be used as a blueprint in the event of a pandemic/outbreak and added to a health system emergency management plan.

Objectives

The aims of the study are to determine best practices from two large-scale, academic medical centers’ employee coronavirus 2019 (COVID-19) vaccination clinics and to apply them to create scalable modules for rapid administration of 10,000 vaccinations.

Methods

The weekly number of COVID-19 vaccine doses administered was captured. Processes were compared to determine best practices, which informed the scalable financial model.

Results

Within the first 3 months, more than 60,000 COVID-19 vaccine doses were administered, and 70% of employees were fully vaccinated in 4 months with more than 95% by the vaccine mandate deadline. The estimated cost of delivering one dose was $29.95 ($299,505/10,000) compared with $35–$39 per dose when delivered by an on-site retail pharmacy.

Conclusions

Successful, safe, and rapid delivery of more than 60,000 COVID-19 vaccine doses in 3 months is practical and scalable. Learnings go beyond COVID-19 and can be applied to future outbreaks/pandemics.

CME Learning Objectives

After completing this enduring educational activity, the learner will be better able to:

• Determine essential elements for a scalable COVID-19 Vaccine Clinic

• Explain how to optimize plans to vaccinate large numbers of individuals efficiently and safely

• Discuss creating a blueprint for COVID-19 vaccination that can be added to a pandemic preparedness plan

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the causative agent of coronavirus 2019 (COVID-19), was identified in December 2019 and became the first new occupational disease in a decade. Declared a worldwide pandemic by the World Health Organization on March 11, 2020,^1,2 COVID-19 presented a formidable challenge to healthcare organizations whose core business relies on healthcare personnel (HCP).³ A vaccine was first available in the United States (US) in December 2020 when the Pfizer BioNTech® vaccine was authorized under the Emergency Use Authorization.^4,5 Vaccination was critical in allowing healthcare personnel to continue to provide quality care during the COVID-19 pandemic. Healthcare organizations had to rapidly innovate and strategize how best to mobilize human and financial resources to vaccinate their employees, with less than a month’s notice, while continuing their core business of efficient, safe, and quality patient care.³

The University of Pennsylvania (Penn) and the Johns Hopkins (JH) Health Systems were faced with the challenge of expeditiously creating and scaling employee COVID-19 vaccine clinics. While their occupational and environmental medicine (OEM) sections routinely provided mandated employee vaccinations (eg, influenza, hepatitis B) and managed the 2009 H1N1⁶ pandemic, a vaccination program at the scale required by this pandemic had never been developed. Rapidly administering thousands of vaccine doses per week in an equitable, socially distanced manner, with careful attention to vaccine handling⁷ would require a well-orchestrated and efficient system.

Hurdles to overcome included staffing and financing the operation and overcoming vaccine hesitancy. Stratification and distribution of this initially scarce resource, keeping protocols current with the whirlwind output of new scientific information and recommendations, harnessing the power of information technology (IT), and addressing adverse reactions some yet unknown presented other challenges.

Considering equity and the initial limited vaccine supply, and using rapid cycle improvement principles, specific objectives of the vaccination program were to: (1) rapidly establish a seamless, efficient large-scale vaccination clinic; (2) safely and swiftly vaccinate as many employees as possible; (3) educate employees on COVID-19 vaccine safety and efficacy; (4) address vaccine hesitancy; and (5) ensure informed consent.

This study compared the best practices at each location for the planning and implementation of rapid vaccine administration to hundreds of employees. A financial readiness plan based on best practices to rapidly administer vaccine to a scalable module of 10,000 individuals was developed, which can be added to a health system emergency management plan toolbox for future pandemic preparedness.

METHODS

Planning Team

Anticipating vaccine availability by the end of 2020, the chief medical officer at the Penn initiated a large multidisciplinary COVID-19 Internal Vaccine Advisory Committee in mid-November 2020, 1 month before the first vaccine doses were available. The JH convened a small executive advisory group 3 weeks prior and a larger multidisciplinary planning group closer to the vaccine delivery date. These leadership groups created the plan to execute the mission adhering to evolving national guidance (Table 1). Both Penn and JH administered vaccine on the first day of availability, December 16, 2020.

TABLE 1.

Vaccine Committee Membership—University of Pennsylvania and Johns Hopkins Health Systems

Group	Penn Vaccine Advisory Committee	JH Vaccine Planning Committee
Chief medical officer senior vice president	X
Senior vice president of operations		X
Chief quality officer	X
Occupational and environmental medicine	x	X
Pharmacy	X	X
Infectious diseases	X	X
Legal	X	X
Ambulatory services		X
Information technology	X	X
Human resources	X	X
Nursing leadership	X	X
Electronic medical record group	X	X
Scarce resources		X
Emergency management	X	X
Supply chain	X	X
General medicine		X
Communications	X	X
Administrative fellow	X	X
Human resource information system	X
Security	X	X
Administrative fellow	X

JH, Johns Hopkins; Penn, University of Pennsylvania.

• Planning committees addressed staffing, complex vaccine handling given specific cold chain requirements, minimization of vaccine wastage, security, equitable allocation, updated state and national guidance, vaccine hesitancy, legal and ethical issues, IT needs, supplies (medical, nutritional, administrative), and iteratively improving processes to increase efficiency while maintaining safety. Meeting daily initially and then less frequently, the committees identified large, well-lit, easily accessible areas proximal to emergency services that permitted social distancing, one-way flow for vaccine administration, and a safe, welcoming environment for vaccinees. Snacks and beverages were available.

Day 1 Pilot

Both hospitals conducted a half-day “practice run” on the first day of availability, vaccinating a small number of employees. This pilot was critical in resolving minor issues, assuring clinic flow, identifying frequently asked questions, and building staff confidence for this new vaccine.

Training and Continuing Education

Vaccinators underwent required training as per the Centers for Disease Control and Prevention (CDC) guidance. Both used online training, although the Penn initially used traditional paper-training modules. The committees created standard operating procedures (SOPs) and training materials, updating them as guidance changed. Both had a centralized, online repository for training materials and SOP while also updating staff via email and in-person huddles. Penn’s OEM COVID-19 Vaccine Clinic Medical Director created a widely circulated comprehensive playbook, which housed training materials, SOPs, and relevant journal articles, which was successfully used for state and federal agency audits (Table 1). Accompanied by a recorded lecture, it served as a ready training tool and reference for operationalizing the employee and community vaccine clinics.

Clinic Workflow and Supplies

The workflows are summarized in Figure 1. Floor and eye level signage, with flow managers to ensure one-way flow of vaccines, were successfully employed. Nurses and pharmacists administered vaccine. The JH also utilized medical students and medical assistants. Availability of required CDC supplies to address allergic reactions was assured (Fig. 1). Electronic medical record (EMR) accessible after-visit summaries, as well as on-site paper copies describing side effects and when to seek medical attention were provided.

FIGURE 1.

Clinic workflow.

The required CDC 15- to 30-minute postvaccination observation period was supervised by a nurse practitioner or Advanced Cardiovascular Life Support–trained nurse (Penn) and by an emergency medical technician (JH). Employees self-timed. At the Penn, employees relinquished their vaccine card at the observation area, which was returned when time elapsed. Templated EMR notes were written for each employee (Penn) or de novo in the event of an adverse reaction (JH). Both provided on-site security.

Consenting Process

An IT solution created at the JH allowed HCPs to confirm their vaccine eligibility in the EMR based on the honor system, determine vaccine contraindications, consent for vaccination, and then schedule the vaccination before arrival in the vaccine clinic. In-person electronic consent was available as needed. Penn relied on in-person paper consent obtained by trained consenters, later completed by the vaccinator, and online scheduling with phone option. Both created a hotline to field questions.

Staffing and Clinic Hours

Each clinic had a lead nurse, pharmacist, and administrator who led morning huddles to review assignments and address questions, as well as a physician on site (Penn) or on-call (JH). Planning committees created staffing models (Table 2) to allow for safe administration of hundreds of vaccine doses daily, based on the number of vaccines per hour. The Penn initially allotted 15 minutes per vaccination, reducing to 5–7 minutes per vaccination, and started with 12-hour weekday clinic hours, reducing to 8 hours. The JH consistently administered one dose per 5 minutes—efficiencies gained given online consenting and education before clinic arrival (Fig. 1), with 8-hour weekday hours. Initial weekend hours (8 hours [Penn] and 4 hours [JH]) were later eliminated as demand eased.

TABLE 2.

Financial Model to Vaccinate 10,000 Healthcare Personnel (2021 Dollars)

No. Daily Administered Vaccines	Scenario 1	Scenario 2	Scenario 3
Average vaccination throughput time, min	5	7	10
No. daily administered vaccines	1,344	960	672
Time required to administer 10,000 doses, d	8	11	15
Staffing cost for 10,000 doses	$89,649	$123,267	$168,091
Supply cost for 10,000 doses	$207,195	$207,195	$207,195
IT cost (software, hardware, and setup)	$2,660	$2,660	$2,660
Total cost for 10,000 doses	$299,504	$333,122	$377,946
Total cost per person	$29.95	$33.31	$37.79

Assumptions: (1) no rent or facility fee, (2) vaccine administered by nurse or pharmacy technician at RN salary, (3) no compensation for hospital leadership and support, (4) no additional cost for IT support or on call physician, and (5) assumes 8-hour employee shifts with 1-hour lunch.

IT, information technology.

COVID-19 Education

Vaccine safety and efficacy data were communicated via multiple methods to insure employee equity and inclusion regardless of occupational group, demographic, or technology skills. Grand rounds, messages from leaders, news tickers, screen savers, banners, educational emails, town halls (often focused on brown and black communities) 1:1 huddles, small group informational sessions, videotaped informational meetings, and tables staffed by physicians to provide information from a trusted source were used.^8,9

Postvaccination Adverse Event Follow-up

Both hospitals gave instructions to employees on how to voluntarily report adverse events (AEs) to the CDC vsafe system. The Penn created an active surveillance system where employees could opt to receive four text messages querying AEs on days 2, 5, 10, and 15. An OEM resident followed up on positive responses.

Information Technology

Information technology was essential in adding significant efficiency in scheduling, education, consenting (JH), and appointment reminders. Both Penn and JH created systems that ensured approval for and migration of HCP vaccination information to HR vaccination recordkeeping systems and that informed mandatory city and state health department databases, and the public health immunization registries.

Hurdles

Vaccine Allocation Principles

Because of initial limited vaccine availability, both health systems created a prioritization scheme, emphasizing level of risk during patient care, and ethical principles in line with the CDC^10,11 recommendations. The Penn created five HCP groups, with each sequentially eligible for vaccination.⁸ The JH identified HCP in the highest-risk categories and stratified them by lottery. Overall, the prioritization process was laborious. Despite broad systemwide emails and small group meetings, many HCP expressed displeasure at not being in an earlier group. Fortunately, supply increased, such that all HCP could access vaccine after 4 weeks of availability.

Vaccine Equity/Access

Outreach strategies were implemented to reduce identified inequities in vaccine access (eg, limited computer access or skills leading to missed relevant emails and/or difficulty scheduling appointments). Partnering with managers to allow employees flexibility to secure vaccine education and in person scheduling was beneficial.^8,11

Consenting

Although in person consenting (Penn) gave comfort to employees as the vaccine was novel, it was labor and human resource intensive. The JH, using mainly electronic consent via the EMR, increased efficiency.

Vaccine Hesitancy

The newness of the vaccine and nationwide trends suggested that vaccine hesitancy could be significant. The Penn rapidly surveyed its employees before vaccine introduction¹² assessing interest in and knowledge of the vaccine. Vaccination strategies were developed based on safety concerns and educational needs. An increase in vaccine uptake compared with reported vaccination intention was noted at the Penn with the largest increase in Black HCP (27%), followed by Hispanic (26%), White (17%), multiracial (16%), and Asian or Pacific Islander (14%) HCPs. Acceptance by women also increased 18%.^13,14 The JH hesitancy strategy was based on lay press nationwide and local vaccination trends and feedback from community forums held on campus.

Medical and Religious Exemptions/Exceptions

As both hospitals allowed medical and religious exemptions (Penn) and exceptions (JH), a method had to be developed to expeditiously address this. Religious exemptions/exceptions were adjudicated by HR and Legal using prespecified criteria. At Penn, medical exemptions guidelines detailed by infection control and legal with OEM input guided case adjudication by OEM physicians. Unresolved cases were escalated to hospital chief medical officers. At the JH, an exceptions committee, consisting of legal, OEM, and compliance, met regularly to adjudicate cases.

Financial Support

Establishment and operation of a large vaccination clinic required immediate and significant expenditures beyond those associated with usual OEM vaccinations. Both institutions established a central separate budget for the vaccine clinics.

Allergy Referrals and AE Handling

Allergy referrals for expert assessment of AEs and vaccine contraindications were challenging. The Penn rapidly developed a formal referral system to a designated allergist who responded to queries and evaluated employees promptly. In addition, a system was arranged for high-risk employees to be administered vaccine under monitored conditions with an allergy trained nurse practitioner.⁸ At the JH, HCPs were evaluated by community allergists with timely appointments. High-risk employees were monitored more aggressively with EMS on-site.

Staffing

Staffing was a significant challenge. The JH initially utilized volunteers (nurses, physicians, pharmacists, and students) but transitioned to paid positions to standardize work force compensation. The Penn relied on redeployed staff,³ overtime workers, and volunteers. Both hospitals relied on temporary agency nursing staff to fill gaps.

The Team

The multidisciplinary team that implemented the vaccination clinic at each hospital is described in Table 1.

RESULTS

Number of Doses Administered

The number of first and second vaccine doses administered by each health system’s main hospital within the first 3 months was 28,575 (Penn) and 33,213 (JH) (Fig. 2). Within 4 months, 70% of health system employees were vaccinated, and more than 95% were vaccinated by the vaccine mandate deadline (11/1/2021-JH; 9/1/2021-Penn) with no deaths or work disability because of vaccination. Less than 0.2% were separated from the institution for noncompliance. Vaccine throughput was one every 7 (Penn) or 5 (JH) minutes.

FIGURE 2.

The number of vaccine doses administered by each health system’s main hospital within the first 3 months.

Best Practices

The best practices identified at each clinic are outlined in Table 3.

TABLE 3.

Best Practices From Vaccine Clinics

Both Vaccine Clinics	PENN Only	JH Only
Vaccine Advisory Committee created to plan rapid, efficient vaccine deployment approximately 1 mo before vaccine arrival	Headed by chief medical officer	Headed by VP clinical operations
Committee members included major stakeholders: occupational medicine, pharmacy, infection control, nursing, information technology, legal, human resources, equity, and quality		Scarce resource group tasked with determining scarce resource allocation
Strategic, organized systemwide unified communication and small group meetings on topics such as vaccine education and hesitancy
Daily meetings discussing vaccine storage and allocation, staffing, medical supplies, legal/ethical issues, IT, security, equity, SOPs, CDC compliance, signage, schedules, staffing, and number of vaccines administered per hour
Electronic consent ahead of vaccination Electronic storage of all standard operating procedures, forms, etc. Electronic scheduling	Consented while in clinic	Consented before arrival to clinic* with in-clinic option
Implementation plan involving: -Pharmacists (prepare dose, manage limited vaccine supply, avoid waste) -Flow manager (to ensure forward flow) -EMR used to consent HCP -EMR used to schedule appointment—phone scheduling available -IT solution for employee attestation to data sharing with the city/state -Special COVID-19 fund -COVID-19 hotline for employee questions		Wipeable chairs* (to reduce risk infectious disease transmission)
Three covering physicians	On-site	On-call
Committee reviewed allergic reactions	Refer to designated* allergist	Refer to community allergists
Vaccine reaction management plan. Instructed to: -Follow up with a primary care provider or with the ED if needed -Report reactions to CDC V-safe	-Same-day appointment with designated Telehealth PCP* -No ED copay* -Text message system to query symptoms post-vaccine	Refer to PCP

Best practice selected is marked with an asterisk (*) if a choice is presented.

CDC, Centers for Disease Control and Prevention; ED, emergency department; EMR, electronic medical record; HCP, healthcare personnel; IT, information technology; JH, Johns Hopkins; Penn, University of Pennsylvania; PCP, primary care provider; SOP, standard operating procedure.

Scalable Financial Model to Vaccinate 10,000 HCPs

A financial readiness plan to rapidly administer a replicable scalable module of 10,000 vaccinations for future pandemic preparedness based on best practices was created. Three scenarios were evaluated based on time allocated for vaccination, a critical rate limiting step. Based on best practices, the estimated cost of delivering a COVID-19 vaccine to an employee was $29.95 (Tables 4, 5) compared with the $35–$39 per dose cost paid by health systems for commercial retail pharmacy on-site administration. Assumptions include the following: (1) no vaccine, rent or facility fee, (2) vaccine administered by nurse or pharmacist, (3) no compensation for hospital leadership planning and support, and (4) no additional costs for the on-call physician and IT support. Process steps were assumed to keep pace with the vaccinator.

TABLE 4.

Staffing Model and Costs to Vaccinate 10,000 Healthcare Personnel (2021 Dollars)

Employee Position	#	Hourly Rate	8 hr/d	8-Day Model	11-Day Model	15-Day Model
Vaccinators	16	$38.46	$4,923	$39,383	$54,152	$73,843
Registrars (2 per clinic)	2	$19.23	$308	$2,461	$3,384	$4,615
Throughput coordinators (1 per clinic)	1	$14.42	$115	$923	$1,269	$1,730
Postvaccination observers (1 per every 6 vaccinators)	3	$52.90	$1,270	$10,157	$13,966	$19,044
Postvaccination scheduler (1 per every 3 vaccinators)	6	$19.23	$923	$7,384	$10,153	$13,846
Pharmacists (2 per every 300 appointments)	4	$61.88	$1,980	$15,841	$21,782	$29,702
Clinical lead (1 per clinic)	1	$38.46	$308	$2,461	$3,384	$4,615
Operations lead (1 per clinic)	1	$48.08	$385	$3,077	$4,231	$5,770
Pharmacy lead (1 per clinic)	1	$61.88	$495	$3,960	$5,445	$7,426
Security guards (2 per clinic)	2	$16.83	$269	$2,154	$2,962	$4,039
Environmental service workers (2 per clinic)	2	$14.42	$231	$1,846	$2,538	$3,461
Totals	39			$89,649	$123,267	$168,091

TABLE 5.

Supply and Information Technology Costs to Vaccinate 10,000 Healthcare Personnel (2021 Dollars)

Item Type	Item Description	Unit Cost	Item Quantity	Total Cost
Medical	Pairs of gloves	$0.34	10,000	$3,400
Medical	2 × 2 gauze (10,000)	$0.049	10,000	$490
Medical	Band-Aids (10,000)	$0.027	10,000	$270
Pharmacy	10,000 vaccines (add 10% for those discarded)	$18.00	11,000	$198,000
Pharmacy	10,000 syringes and needles (add 10% for those discarded)	$0.36	11,000	$3,905
Hospitality	1,000 small water bottles	$0.62	1,000	$620
Hospitality	1,000 apple juice boxes	$0.37	1,000	$370
Hospitality	1,000 individual packets of crackers	$0.14	1,000	$140
Supply totals				$207,195
IT	Laptop computers (monthly rental)	$72.00	30	$2,160
IT	Software developer (hours)	$50.00	8	$400
IT	Hardware setup (hours)	$50.00	2	$100
IT totals				$2,660

DISCUSSION

These two major academic hospitals successfully vaccinated more than 60,000 HCPs within 3 months using key guiding principles. Several best practices were identified in reviewing the processes used at the two vaccination clinics including strong, guiding leadership, multidisciplinary collaboration with key major stakeholders, and frequent, succinct, and effective communication. Priorities were set with clear goals and expectations and processes were managed with continuous improvement with experts engaged to guide the process demonstrating operational excellence. Those involved embraced ambiguity and made high-stakes decisions quickly and iteratively with analytical thinking, judgment, and wisdom using the data they had at hand. Using and disseminating these best practices are important to inform future pandemic preparedness.

The examples of these two mass vaccination clinics in the workplace add support to previous research suggesting that a single location for large-scale vaccination of a specific community results in a rapid, efficient, effective, and more equitable⁷ method to vaccinate large numbers of individuals.^7,15,16 Resources can be consolidated leading to improved vaccine rollout and efficiency.¹⁶ Such large vaccination campaigns rely on adequate resources, such as staff, vaccine supply, and the experience needed to operationalize the process.^8,17–19

The CDC estimated that without COVID-19 vaccines, four times as many individuals would have died, 1.5 times more would have been infected, and 3.8 times more would have been hospitalized in the US, from December 2020 to March 2022, during which time there were more than 1 million deaths. The vaccines also saved the US $1 trillion in additional medical costs.^7,20 The ability to vaccinate large numbers of individuals represents one of the most successful and cost-effective health interventions in human history.²¹ The World Health Organization notes that global vaccination programs save up to 2–3 million lives each year. By preventing these diseases, a challenge to the health and welfare of millions, which would also negatively affect the global economy, is removed²² and lives are saved.²³ The mass vaccination clinics described here clearly helped save the lives of HCP and their patients.

Work is an important social determinant of health,²⁴ and it is well known that vaccination can enhance disease prevention, and the health and well-being of workers and communities.²⁵ The ability to administer vaccines at work is critical to the prevention of infectious disease transmission to coworkers and. in the case of healthcare establishments, to patients.²⁵ The workplace provides a venue where population level interventions can be implemented and structures and policies can be modified in ways that reduce health inequities. In the case of these mass vaccination clinics in the workplace, efforts were made to ensure the equitable administration of the COVID-19 vaccine to all HCP.

Limitations and Strengths

We described two academic center clinics with the capability to amass appropriate resources and looked at the best practices that made them successful. However, these best practices reflecting a new vaccine for a new occupational illness based on the experience of two tertiary care centers may not be generalizable to smaller health care settings or to industries with different personnel and costs. However, these models were subsequently used to successfully create community²⁶ and patient clinics, which went on to administer hundreds of thousands of vaccines.

CONCLUSIONS

The success of future, large-scale vaccine clinics can be enhanced through the application of the multidisciplinary approach described here, including inclusive, intensive planning, standardization, efficient information dissemination, and IT solutions. Using lessons learned to invest in infrastructure, setting aside funding for a scalable module for vaccine administration, with contingency planning efforts and continuous improvement, will strengthen health systems and build capacity^27,28 to face future pandemics. This blueprint for a pandemic preparedness vaccine administration plan can be added to a health system emergency management plan. Learnings go beyond COVID-19 vaccine and should be applicable in future outbreaks/pandemics.