Understanding Human Factors Challenges on the Front Lines of Mass COVID-19 Vaccination Clinics: Human Systems Modeling Study
Authors: Tennant Ryan , Tetui Moses , Grindrod Kelly , Burns Catherine M 
Published: October 2022

Background
Implementing mass vaccination clinics for COVID-19 immunization has been a successful public health activity worldwide. However, this tightly coupled system has many logistical challenges, leading to increased workplace stress, as evidenced throughout the pandemic. The complexities of mass vaccination clinics that combine multidisciplinary teams working within nonclinical environments are yet to be understood through a human systems perspective.

Objective
This study aimed to holistically model mass COVID-19 vaccination clinics in the Region of Waterloo, Ontario, Canada, to understand the challenges centered around frontline workers and to inform clinic design and technological recommendations that can minimize the systemic inefficiencies that contribute to workplace stress.

Methods
An ethnographic approach was guided by contextual inquiry to gather data on work as done in these ad-hoc immunization settings. Observation data were clarified by speaking with clinic staff, and the research team discussed the observation data regularly throughout the data collection period. Data were analyzed by combining aspects of the contextual design framework and cognitive work analysis, and building workplace models that can identify the stress points and interconnections within mass vaccination clinic flow, developed artifacts, culture, physical layouts, and decision-making.

Results
Observations were conducted at 6 mass COVID-19 vaccination clinics over 4 weeks in 2021. The workflow model depicted challenges with maintaining situational awareness about client intake and vaccine preparation among decision-makers. The artifacts model visualized how separately developed tools for the vaccine lead and clinic lead may support cognitive tasks through data synthesis. However, their effectiveness depends on sharing accurate and timely data. The cultural model indicated that perspectives on how to effectively achieve mass immunization might impact workplace stress with changes to responsibilities. This depends on the aggressive or relaxed approach toward minimizing vaccine waste while adapting to changing policies, regulations, and vaccine scarcity. The physical model suggested that the co-location of workstations may influence decision-making coordination. Finally, the decision ladder described the decision-making steps for managing end-of-day doses, highlighting challenges with data uncertainty and ways to support expertise.

Conclusions
Modeling mass COVID-19 vaccination clinics from a human systems perspective identified 2 high-level opportunities for improving the inefficiencies within this health care delivery system. First, clinics may become more resilient to unexpected changes in client intake or vaccine preparation using strategies and artifacts that standardize data gathering and synthesis, thereby reducing uncertainties for end-of-day dose decision-making. Second, improving data sharing among staff by co-locating their workstations and implementing collaborative artifacts that support a collective understanding of the state of the clinic may reduce system complexity by improving shared situational awareness. Future research should examine how the developed models apply to immunization settings beyond the Region of Waterloo and evaluate the impact of the recommendations on workflow coordination, stress, and decision-making.