Washington State was the first U.S. state to have a patient test positive for COVID-19. Prior to this, our children's hospital proactively implemented an incident command structure which allowed for collaborative creation of safety measures, policies and procedures for both patients, families, staff and providers. Although the treatment and protective standards are continuously evolving, this commentary shares our thoughts on how an institution, specifically surgical services may develop collaborative process improvement to accommodate for rapid and ongoing change. Specific changes outlined include [1] early establishment of incident command [2] personal protective equipment conservation, [3] workforce safety, [4] surgical and ambulatory patient triage, and [5] optimization of trainee education. Please note that the contents of this manuscript are shared in the interest of providing collaborative information and are under continuous development as our regional situation changes. We recognize the limitations of this commentary and do not suggest that our approaches represent validated best practices.